Inspection on 17/08/05 for Holyrood House

This inspection was carried out on 17th August 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 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

Holyrood House 22/01/09

Holyrood House 22/11/07

Holyrood House 21/06/07

Holyrood House 06/07/06

Holyrood House 20/12/05

Holyrood House 10/03/05

Holyrood House 13/01/05

Holyrood House 20/02/04

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Holyrood House 46 Green Lane Ostend Burnham on Crouch Maldon Essex CM0 8PU Lead Inspector Brian Bailey Final Report Unannounced 17th & 18th August 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. Holyrood House I56 105 S17852 Holyrood Hse V245093 UI 17.8.05 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Holyrood House Address 46 Green Lane, Ostend, Burnham on Crouch, Maldon Essex CM0 8PU 01621 784759 01621 784856 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) Mr Peter Walters Mrs Melanie Walters Mrs Melanie Walters Care Home 3 Category(ies) of Old age, not falling within any other category registration, with number (3) of places Holyrood House I56 105 S17852 Holyrood Hse V245093 UI 17.8.05 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 10th March 2005 Brief Description of the Service: Holyrood House is a detached property that was first registered as a private care home for three older people in 1994. The proprietors are Mr & Mrs P Walters. This home is situated on the outskirts of Burnham on Crouch but is not within walking distance of the towns facilities. Holyrood House caters for older people with low to medium dependency levels in a homely environment, which they share with the proprietors. Being a family home, residents are treated as family friends and receive consistent day-to-day care and involvement with the proprietors (registered providers) and a small team of care staff. Residents are encouraged to treat the home as their own and to be involved in the daily routines of running a house. Residents private accommodation is in single bedrooms on the ground floor. Access to the front of building is good although the rear garden/patio area would be difficult for wheelchair users. Car parking facilities are available at the side of the property. Holyrood House I56 105 S17852 Holyrood Hse V245093 UI 17.8.05 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 17th August 2005 at 10.45am and by appointment with the manager on 18th August at 2.30pm. This was the first inspection of Holyrood House in the inspection year 2005/06. On the first day, one member of staff was on duty and there were three residents at home, all were spoken with. The inspection included a check of the bedrooms, lounge, dining room, care records, medication, menus, lunch, and health and safety records. Discussions with residents concluded that they were happy living at Holyrood and had no concerns about the way the home is run. All felt safe and content and liked the staff. What the service does well: What has improved since the last inspection? What they could do better: The forms used for recording the administration of medication need to be reviewed and standardised to ensure consistency and minimise the risk of errors. Holyrood House I56 105 S17852 Holyrood Hse V245093 UI 17.8.05 Stage 4.doc Version 1.40 Page 6 Health and Safety matters such as risk assessments of the building, Control of Substances Hazardous to Health data sheets, policies and procedures and documents relating to the servicing of equipment and fire precautions should be more accessible and always available for inspection. The maintenance of a log or a file of all Health & Safety documentation would be beneficial. 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. Holyrood House I56 105 S17852 Holyrood Hse V245093 UI 17.8.05 Stage 4.doc Version 1.40 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 Holyrood House I56 105 S17852 Holyrood Hse V245093 UI 17.8.05 Stage 4.doc Version 1.40 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. Clear information about the home is made available and prospective residents and relatives are able to visit to determine whether the home is suitable. EVIDENCE: A statement of purpose and a service users guide were available, which had been amended to meet the requirements of the National Minimum Standards. Residents are encouraged to visit the home prior to admission. The home’s Statement of Terms and Conditions between the home and residents was seen and evidence that a resident had signed this. The statement includes what is included in the fees charges and those items considered as extra. Evidence was available to show that the manager obtains assessments for prospective service users and completes her own assessment. This procedure conforms to the home’s statement of purpose that states that the manager would visit prospective residents in their own setting and complete the home’s assessment forms. Holyrood House I56 105 S17852 Holyrood Hse V245093 UI 17.8.05 Stage 4.doc Version 1.40 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, 9 & 10 Personal support in this home is offered in such a way as to promote and protect residents’ privacy, dignity and independence. EVIDENCE: Care records for each resident were looked at. Each resident had a care plan on their files that detailed a range of needs that staff were familiar with. Records showed that these had been reviewed on a regular basis. With three residents only living at the home, staff were aware of each person’s preferences, their health, likes and dislikes and the daily routines they like to follow. Residents spoke of being able to get up in the morning when they like and rest in their rooms if they prefer. One resident said “ I don’t want for anything, I am very satisfied”, and described the bed as comfortable with clean bed linen, having good food and able to do what they like. Residents said the care staff were kind and patient and respected their privacy. All medication is kept in a locked cupboard. Medication administration record sheets were available to show that medication had been administered at the appropriate intervals and the forms were up to date. The record sheets were however, varied in layout and some were not dated. It is important that staff use the same type of record, and that these are dated so as minimise the risk of an error in administration. Evidence was not available to show that staff Holyrood House I56 105 S17852 Holyrood Hse V245093 UI 17.8.05 Stage 4.doc Version 1.40 Page 10 responsible for the administration of medication had received appropriate training to assess their competency. Holyrood House I56 105 S17852 Holyrood Hse V245093 UI 17.8.05 Stage 4.doc Version 1.40 Page 11 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 14 & 15. Residents are able to maintain and develop contacts with friends and family and experience an open and welcoming home. Residents are able to act independently to the greatest possible extent and to move freely around the home within safe boundaries. Residents are provided with a varied and healthy diet. EVIDENCE: Residents spoken with were satisfied with the home; they liked being free to choose where they wanted to spend their time. They didn’t feel restricted by rules and spoke of preferring their own company although they enjoyed visitors and taking with staff. The atmosphere throughout the inspection was calm and relaxed as staff went about their duties and were seen to chat with residents at frequent intervals. Residents spoken with said they liked the food; they felt they had sufficient and had no complaints. The midday meal was well presented and enjoyed by residents. There were adequate food stocks available including fresh fruit. Records were available that showed the meals provided to each resident. Holyrood House I56 105 S17852 Holyrood Hse V245093 UI 17.8.05 Stage 4.doc Version 1.40 Page 12 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 & 18. The home has appropriate arrangements in place to protect residents from abuse and to listen to any concerns or complaints, but it is essential that all staff attend the training course planned for October 2005. EVIDENCE: The home has a complaints procedure. No complaints have been received at the home or by CSCI since the last inspection. There was also policy and procedure on the protection of vulnerable adults from abuse and a whistle blowing policy. The manager has arranged for staff to attend a training course on understanding abuse in October/November 2005. Holyrood House I56 105 S17852 Holyrood Hse V245093 UI 17.8.05 Stage 4.doc Version 1.40 Page 13 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, 23, 24, 25 & 26. The standard of the environment within this home is good providing residents with an attractive and homely place to live, however, up grading the bathroom and making the patio area a safer place to walk would be of benefit to residents. EVIDENCE: Holyrood is a large detached property that blends in well with the neighbouring properties. Residents’ private accommodation consists of three single bedrooms, each with en-suite WC facilities, which are on the ground floor. All bedrooms were bright and cheerful and had been personalised. Communal rooms consist of a lounge and dining room that overlooks the rear garden. The front door has a step that would present a difficulty for wheelchair users. The patio area is uneven and has steps that could present a trip hazard to residents. Unrestricted car parking is available at the side of the property. All rooms were clean and tidy including the kitchen, which was well equipped. Residents were observed to have free access to all communal areas within the home. Holyrood House I56 105 S17852 Holyrood Hse V245093 UI 17.8.05 Stage 4.doc Version 1.40 Page 14 The manager stated that the next project is to re carpet the lounge and the dining room and to fit patio doors in the dining room. The bathroom has a hoist installed but the room is need of modernisation. Holyrood House I56 105 S17852 Holyrood Hse V245093 UI 17.8.05 Stage 4.doc Version 1.40 Page 15 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 & 30. Residents benefit from being supported by a small team of experienced and motivated staff. EVIDENCE: A small team of staff that includes the manager staff the home. A staff roster showed that there are sufficient staff on duty each day. None of the staff are under 18 years of age and staff left in charge are over the age of 21 years. One staff member is currently taking a National Vocational Qualification at level 2 and plans to proceed with level 3. Holyrood House I56 105 S17852 Holyrood Hse V245093 UI 17.8.05 Stage 4.doc Version 1.40 Page 16 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, 33 & 38 Residents live in a well-managed and safe environment but unless evidence is available to show that essential equipment or systems are serviced at the appropriate intervals, residents may be placed at risk. EVIDENCE: The managers is in the process of completing a National Vocational Qualification level 4 in management and care and will also take the Registered Managers Award. Evidence was available to show that the manager had started to obtain feedback from relatives as part of a Quality Assurance system. The system will need to be expanded to included residents and other persons that visit the home, such as health care professionals. Information relating to Health and Safety matters was not readily available. An Environmental Health Officer visited the home on 4/3/05 and concluded that the home had good standards at the time of inspection. The manager had Holyrood House I56 105 S17852 Holyrood Hse V245093 UI 17.8.05 Stage 4.doc Version 1.40 Page 17 arranged for a fire officer to attend the home to check the fire precautions and obtain advice on producing a fire risk assessment. The fire detection system was serviced 2/8/05. Information relating to all aspects of health and safety at the home needs to be more accessible and should be kept ideally in one file as a log of events. Holyrood House I56 105 S17852 Holyrood Hse V245093 UI 17.8.05 Stage 4.doc Version 1.40 Page 18 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 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 3 COMPLAINTS AND PROTECTION 3 2 2 x 3 x 3 3 STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 2 x 3 x x x x 2 Holyrood House I56 105 S17852 Holyrood Hse V245093 UI 17.8.05 Stage 4.doc Version 1.40 Page 19 no 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 9 Regulation 13 Requirement Staff that administer medication must receive training that includes an assessment of their competency, preferably by an external assessor. The registered person must ensure that all staff are provided with training on the protection of vulnerable adults from abuse. (Timescale of 1/7/05 not met) The patio area must be made safe for residents to use. Timescale for action 1/12/05 2. 18 13 1/12/05 3. 4. 20 23 1/1/06 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. 2. Refer to Standard 21 38 Good Practice Recommendations The bathroom should be up graded to make the facilities more comfortable and welcoming. That all documentaion relating to Health & Safety at the home is kept in a file for easy access. Holyrood House I56 105 S17852 Holyrood Hse V245093 UI 17.8.05 Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection Fairfax House Causton Road Colchster Essex CO1 1RJ 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 Holyrood House I56 105 S17852 Holyrood Hse V245093 UI 17.8.05 Stage 4.doc Version 1.40 Page 21 - 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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