CARE HOMES FOR OLDER PEOPLE
Halcyon Days The Old Rectory Church Lane Graveley Nr. Stevenage Hertfordshire SG4 7LU Lead Inspector
Mr Neil Fernando Unannounced Inspection 3rd February 2006 10:10 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.V283412.R01.S.doc Version 5.1 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.V283412.R01.S.doc Version 5.1 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 Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33) of places Halcyon Days DS0000019403.V283412.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 14th September 2005 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 DS0000019403.V283412.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This is the last inspection for the inspection year 2005/6. The last inspection was carried out on 14.09.05. The inspection visit lasted for approximately 5 hours and during which time 9 service users and most of the staff members on duty were spoken to. A number of records were examined and a tour of the premises was also undertaken. Halcyon Days is a residential care home owned and managed by Karlamain Limited. It accommodates up to 33 elderly people. At the time of the visit there were 29 service users in residence. Standards not assessed during this visit were covered during the inspection that took place on 14 September 2005. What the service does well: What has improved since the last inspection?
Halcyon Days DS0000019403.V283412.R01.S.doc Version 5.1 Page 6 The staffing arrangements are satisfactory. Training continues to be given high priority. There is evidence of a committed and supportive Manager. There were 2 recommendations arising from the last inspection report. These have been met, bar one, which has been partly addressed. The names of staff participating in fire drills are recorded and this practice enables management to ensure that no staff members miss this essential training. The care plan for new service users’ now reflects their identified cultural and religious needs; this is a more holistic approach to the care planning process. The Gold Care Homes Organisation has managed to retain most of its core staff members, hence generating a higher degree of consistency and continuity in the quality of service delivery. Good progress is being made in promoting NVQ assessment for staff. A Registered Manager is now in post and she is well supported by her Line Manager. There are many examples of new systems she plans to introduce, which will further improve this already good service. 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.V283412.R01.S.doc Version 5.1 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.V283412.R01.S.doc Version 5.1 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 and 4. Standard 6 is not applicable. The information available to prospective service users is comprehensive and informative. The pre-admission assessment is thorough and involves the service user and significant others, ensuring that their identified needs would be met. A trial period further assists the decision making process. EVIDENCE: The home has an up-to-date statement of purpose and a service user’s guide to the home. Evidence available indicates that a copy of the guide is made available to the service user, their representative and professionals, as appropriate. Staff members also assist service users where clarification is needed. A copy of the service users’ guide was seen and the Manager is in the process of updating this document, in order to include details of the qualifications and experience of staff. Staff members including the Manager reported that any prospective service user, their relatives/friends are always encouraged to visit and an overnight stay for the prospective resident will be facilitated, as appropriate. The opportunity to meet with residents and staff members, have a meal and seek clarification, appear to be a routine part of the admission process. A ‘settling
Halcyon Days DS0000019403.V283412.R01.S.doc Version 5.1 Page 9 in’ trial period of residence would then be offered, followed by a placement review with the service user, Social Worker, their relatives and other professionals. Case files for 10 service users indicate that a comprehensive assessment of needs is carried out by the Manager including the service user and significant others. Halcyon Days DS0000019403.V283412.R01.S.doc Version 5.1 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 and 10. All aspects of health and personal care are being delivered appropriately. Staff members continuously monitor residents’ health and general well being, and maintain relevant records. The service users observed during the course of the inspection appeared to be well cared for and they were treated with dignity and respect. EVIDENCE: The initial assessment of needs forms the basis of the individual care plan. Information gained from a sample of 10 care plans, service users and staff members demonstrates that the needs of residents are being identified and addressed satisfactorily. A record of the care given, progress made and interactions with service users is maintained on each shift. Staff members reported that residents are always encouraged to sign their care plans where this is appropriate. Service users provided some good examples of how staff members assist them to address their needs daily. Records show that care plans are being reviewed monthly to reflect the changing needs and objectives for health and personal care. Monthly review notes are maintained and these are noted to be comprehensive.
Halcyon Days DS0000019403.V283412.R01.S.doc Version 5.1 Page 11 Records show that the residents are registered with a local GP of their choice who visits as and when required. The District Nurse leads on the treatment of pressure sore that any service user may develop, including the provision of any equipment necessary for the promotion of tissue viability. The District Nurse currently visits 5 service users weekly. The outcome of the District Nurse and Doctor’s visits is clearly recorded. All service users spoken with expressed a high level of satisfaction in the manner their health care needs are being addressed. Privacy and dignity is a subject included in the induction programme for all staff members. Staff undertake their duties to service users in an unobtrusive and sensitive manner. Service users were observed to be treated with dignity and respect at all times by staff members, during the inspection. Halcyon Days DS0000019403.V283412.R01.S.doc Version 5.1 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 and 15. Service users are clear that the home matched their expectations and preferences. Service users are encouraged and have good contact with family and friends. The food offered is of a good quality and is served in comfortable settings. EVIDENCE: An Activities Co-ordinator has been in post since early August and service users confirmed that her involvement has positively enhanced their social lives. Service users are being assisted to follow the lifestyle of their choice as discussed and agreed during assessment. A random sample of care plans for 10 service users were examined and in the main, these were noted to be comprehensive. However, minor improvements are required. For example some of the care plans viewed did not reflect the identified cultural and religious needs of the particular service users. Service users confirmed that relatives and friends are able to visit them at any time and they are always made welcome. 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. Representatives from the local church visit the home and provide for spiritual expression and friendship.
Halcyon Days DS0000019403.V283412.R01.S.doc Version 5.1 Page 13 The menu seen provided for a nutritious and varied diet. Large windows pleasantly enhance the congenial setting of the dining room. 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 people with whom they have made friends or identify with. The cook meets with service users regularly to discuss the menu periodically and also on request individually. Three service users said that alternative meals are provided if they don’t want the meals on the menu. Snacks and beverages are readily available. Most residents reported that “food is very good”. Halcyon Days DS0000019403.V283412.R01.S.doc Version 5.1 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 and 18. The complaint procedures are well-publicised and service users and significant others should be capable of making a complaint. Further training on Complaints and Adult Protection is indicative of the new Organisation’s commitment to the training of its staff and welfare of its service users. There are a number of systems in place, which should adequately protect a service user. EVIDENCE: The procedures on complaints are available to all staff. Information on how to make a complaint is included in the statement of purpose and the service user’s guides. Many of the service users spoken with said that they are aware of how to make a complaint and they expressed confidence in that any concern raised with staff, will be dealt with speedily and to their satisfaction. This is a subject also discussed at the residents’ and relatives’ meetings. The Manager reported that arrangements are in hand for staff to receive training on complaints in March 2006, which is welcomed by the Commission. The home maintains a record of complaints. Records examined indicate that the home has received 1 complaint since the last inspection in September 2005. Evidence shows that the complaint has been dealt with speedily and satisfactorily. The home has a copy of the Hertfordshire procedures on Adult Protection. Staff members interviewed showed an understanding of the above procedures. All staff have received basic training on the Protection of Vulnerable Adults. Further training has been organised for all members for March 2006. This is a
Halcyon Days DS0000019403.V283412.R01.S.doc Version 5.1 Page 15 subject also included in the induction programme for all new staff members and those people undertaking the NVQ assessment. There has been 1 adult protection matter linked to the 1 complaint referred to earlier. This matter appeared to have been dealt with satisfactorily. There are a number of systems in place, which should adequately protect service users from harm. Halcyon Days DS0000019403.V283412.R01.S.doc Version 5.1 Page 16 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 and 26. The environment is safe, well maintained and service users live in a comfortable surrounding. The standard of cleanliness maintained is commendable. EVIDENCE: Health and Safety Policies and procedures are in place, and these are being updated as necessary by “Gold Care Homes” - the new Owner. Records examined, 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. Furniture and fittings are of a good standard and bedrooms viewed are comfortable. 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 DS0000019403.V283412.R01.S.doc Version 5.1 Page 17 environment is carried out as appropriate. There were no health and safety hazards noted. Halcyon Days DS0000019403.V283412.R01.S.doc Version 5.1 Page 18 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, 29 and 30. Staffing levels are adequate to meet the needs of the current service users. Staff recruitment process is robust, which means that residents are in safe hands. The training needs of staff are being addressed appropriately. EVIDENCE: Staff duty roster for a period of one month was scrutinised and discussion with staff members including the Registered Manager indicates that staffing levels are adequate to meet the needs of the current service users. Information gathered indicates that staff members have adequate experience and skills to enable them deliver a good quality care and service to the resident groups. The recruitment files for the 2 new members who have joined the staff team were viewed. Robust recruitment practices are observed to offer protection to service users and in line with legislation; all documentation including CRB and POVA checks are maintained on these files. Service users and staff interviewed consider the staffing levels to be appropriate and residents were positive about the care and support they received. Staff members spoken with indicate that they have good opportunities for relevant training and this give them greater confidence to do their jobs. The home has not yet achieved the 50 NVQ Level 2 for its staff. 5 care staff members have completed their assessment and 5 are currently working
Halcyon Days DS0000019403.V283412.R01.S.doc Version 5.1 Page 19 towards it. A further 8 members have been signed on the course, on 2.02.06. The home is therefore working towards meeting the stated Standard. Halcyon Days DS0000019403.V283412.R01.S.doc Version 5.1 Page 20 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, 36 and 38. Care and staff management systems including health and safety are being implemented to good effect. The home is a safe place for service users to live in. The Manager must however ensure that all staff members participate in fire drills. Records viewed are maintained in good order. EVIDENCE: The Manager’s application to become the Registered Manager for Halcyon Days has recently been approved by the Commission. She has been the home’s Deputy Manager for 8 years and therefore, has the necessary experience in the management of this establishment and the implementation of the National Minimum Standards. The Manager has an NVQ Level 4 in Management and Care, and she has undertaken periodic training to update her skills and knowledge whilst managing the home. The management systems are transparent and service users and staff members confirmed that the Manager is supportive. Observation of care
Halcyon Days DS0000019403.V283412.R01.S.doc Version 5.1 Page 21 practice during the visit also demonstrates that members of staff and service users enjoy a very good relationship. Staff have received formal one to one supervision every 2 months and details of supervision sessions are recorded. Regular staff meetings are held and members are appreciative of being given the opportunity to raise and seek clarification on issues that matter to them. The home has good procedures to ensure the health and safety and welfare of service users and staff. All staff members have received mandatory training in order to ensure safe working practice. Records show that health and safety checks are carried out and these include fire equipment, gas and the fire alarm system. Hot water temperature and portable electrical appliances are checked as appropriate and an annual fire risk assessment of the building has been completed. Fire drills and weekly test of break glass points have been carried out within the required frequency. All staff spoken to, bar 2 members have participated in a fire drill. The Manager is aware that this requires some attention. Hazardous substances such as disinfectant and cleaning materials are stored in locked cupboards. Halcyon Days DS0000019403.V283412.R01.S.doc Version 5.1 Page 22 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 X 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 X 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 x X X X X X 4 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X 3 x 2 Halcyon Days DS0000019403.V283412.R01.S.doc Version 5.1 Page 23 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 Standard OP38 Regulation 23 (4) Requirement The Manager must ensure that all staff members participate in fire drills. Timescale for action 03/05/06 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 Some care plans should be updated, in order to include the cultural needs and religious preferences of the service users. (Previous recommendation made in last inspection report). Halcyon Days DS0000019403.V283412.R01.S.doc Version 5.1 Page 24 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
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