Inspection on 06/07/06 for Holyrood House

This inspection was carried out on 6th July 2006.

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

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

Other inspections for this house

Holyrood House 22/01/09

Holyrood House 22/11/07

Holyrood House 21/06/07

Holyrood House 20/12/05

Holyrood House 17/08/05

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 Key Unannounced Inspection 11:00 6th July 2006 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 Holyrood House DS0000017852.V298457.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. Holyrood House DS0000017852.V298457.R01.S.doc Version 5.2 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 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) 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 DS0000017852.V298457.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th December 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 owners are Peter and Melanie Walters, who is also the registered manager. 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 three older people with low to medium dependency levels in a homely environment, which they share with the owners. As a family home, residents are able to receive consistent day-to-day care and involvement with the owners 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 the building and the rear garden via the new patio doors is good, although wheelchair users would find it difficult to access the garden. Adequate car parking facilities are available at the side of the property. As at 6th July 2006, the manager advised that the fees for accommodation ranged from £380 to £450 per week. Items considered to be extra to the fees include private chiropody, hairdressing, toiletries and newspapers. CSCI inspection reports are available from the home and the CSCI website. Holyrood House DS0000017852.V298457.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced inspection of Holyrood House was carried out on 6th July 2006. This report is based on a range of information that has been accumulated from our inspection records, a site visit to the home, discussions and observations with service users, the manager and owner and the records kept at the home. Twenty-six standards were assessed, of these twenty-one were met and the remainder were partly met. What the service does well: What has improved since the last inspection? What they could do better: It is recognised that this is a family home where residents and the owners share many of the facilities. However, the location where some residents’ records and correspondence is kept is tending to merge with matters relating to the personal affairs of the family. A clearer distinction needs to be Holyrood House DS0000017852.V298457.R01.S.doc Version 5.2 Page 6 maintained and an improvement made in the way records are kept to ensure that information is retrieved more easily. More attention also needs to be given to ensuring responsibilities under the heading of Health & Safety and staff recruitment are adhered to. 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 DS0000017852.V298457.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 Holyrood House DS0000017852.V298457.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 & 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information about the home is made available and prospective residents and relatives are able to visit to determine whether the home is suitable to meet their needs. EVIDENCE: Prospective residents are encouraged to visit the home to view the accommodation and to see the facilities and to meet staff and the other residents. This is stated in the home’s Statement of Purpose. In practice, it is generally relatives that visit on behalf of their relatives to assess the home although in some cases, people are already aware of the home and have waited for a vacancy to occur. Assessments of need were seen on each of the care files, which had been completed by the manager. Holyrood House DS0000017852.V298457.R01.S.doc Version 5.2 Page 9 The home does not provide an intermediate care service. Holyrood House DS0000017852.V298457.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. 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. Records showed that these had been reviewed but not all on a regular monthly basis. The daily records for the three residents are kept in one book and must be separated to ensure confidentiality is maintained. Visits by health care professionals were recorded. With three residents only living at the home, the manager and her husband were fully aware of each person’s preferences, their health, likes and dislikes and the daily routines they like to follow. Residents spoken to said they were able to get up in the morning when they like and rest in their rooms if they prefer. One person said they were very satisfied with the facilities and the service provided, their privacy was respected and they were treated with Holyrood House DS0000017852.V298457.R01.S.doc Version 5.2 Page 11 dignity when being supported by staff. A district nurse was currently attending one resident, who from observation was comfortable and well cared for. The home has a policy for the administration of medication. Medication records were inspected and found to be up to date. Medication for each service user is kept in a separate box, with their photograph and name on, in a locked cupboard. No controlled drugs are used at present. Since the last inspection, the owners/manager have attended a training course on the administration of medicines. Holyrood House DS0000017852.V298457.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 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: It was evident from observation and discussion with residents that they are content with the level of their involvement in the home and are content with their current lifestyles. A resident spoken to said that visitors are welcome at anytime. The recent dining room adaptations have made the room a private and attractive area for visitors to meet their relatives, although the manager said that the residents do not seem to want to use the room. The home encourages visitors who are free to come and go as they please. None of the residents are able to access the community independently although none have expressed a wish to go out. Holyrood House DS0000017852.V298457.R01.S.doc Version 5.2 Page 13 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 DS0000017852.V298457.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 & 19. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has appropriate arrangements in place to protect residents from abuse and to listen to any complaints. EVIDENCE: The home has a complaints procedure. No complaints have been received at the home or by CSCI about the quality of care and services provided since the last inspection. The home has a policy and procedure on the protection of vulnerable adults from abuse and a whistle blowing policy. The owners/manager attended a course in October 2005 and have passed the information onto the staff. A resident spoken to said that they would not hesitate to complain if the need arose and had in fact spoken to the manager the previous day, but didn’t want to say what the issue had been about. The resident was satisfied and had dismissed the matter. Holyrood House DS0000017852.V298457.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, 23, 25 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment within this home is good providing residents with an attractive and homely place to live, which has been enhanced with the changes to the dining room. The patio area has steps leading to the garden, which could present a trip hazard to residents. EVIDENCE: Holyrood House is a large detached property that is situated in a quiet area on the outskirts of Burnham on Crouch. 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 dining room had been upgraded with new patio doors and windows and new floor covering and some new armchairs. Holyrood House DS0000017852.V298457.R01.S.doc Version 5.2 Page 16 The patio area has steps leading to a private garden, but these 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 is well equipped. Residents are free to access all communal areas within the home, although two residents prefer to stay in their bedrooms. Holyrood House DS0000017852.V298457.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, 28 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: This is a small home managed and run by the registered person/manager and two members of staff. The need for the recruitment of new staff is therefore limited, although there have been two changes of staff since the last inspection. The manager was aware of the need to obtain CRB disclosure checks before staff are employed but had only just applied for checks to be obtained. CRB disclosure checks are not transferable between services. Staff training is continuing that includes health & hygiene, National Vocational Qualification at level 2, POVA and medication. Holyrood House DS0000017852.V298457.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, 37 & 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in a well-managed and safe environment but residents may be placed at risk if essential equipment and systems are not serviced at the appropriate intervals. EVIDENCE: The manager is in the process of completing a National Vocational Qualification level 4 in management and care and will also take the Registered Managers Award. Although the majority of the required records were being maintained appropriately, the current method of storing records is poor resulting in information not always being accessible or readily available. This is a potential Holyrood House DS0000017852.V298457.R01.S.doc Version 5.2 Page 19 hazard, as service dates may be overlooked. The registered owners have full responsibility for maintaining high standards of health and safety. They must therefore ensure that all matters relating to Health & Safety are maintained in a format that enables an audit to be carried out. This is the second occasion that this matter has been highlighted. Only small sums of residents’ money is looked after for safekeeping; records were available that showed that all income and expenditure is recorded and these were accurate and up to date. All expenditure reflected the items considered to be extra to the fees such as toiletries, chiropody and hairdressing. Evidence was available to show that the manager was obtaining feedback from relatives and residents as part of a Quality Assurance system but this was proving difficult to obtain. The system will need to be expanded to include other persons that visit the home, such as health care professionals. Holyrood House DS0000017852.V298457.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 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X 3 X 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X 2 2 Holyrood House DS0000017852.V298457.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? Yes 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 OP7 OP29 Regulation 15 13 Requirement Care plans must be reviewed on a monthly basis. CRB disclosure checks must be obtained for all staff and for new staff before they commence working at the home. (Timescale 1/2/06 not met) The manager must arrange to consult with residents, relatives and other people with an interest in the home at regular intervals as part of a Quality Assurance system All records must be maintained in a manner that ensures confidentiality and available for inspection. The manager must ensure that all matters relating to Health & Safety are up to date and kept available for inspection. Timescale for action 01/09/06 01/09/06 3 OP33 24 01/12/06 4. OP37 17 01/09/06 5 OP38 12 01/09/06 Holyrood House DS0000017852.V298457.R01.S.doc Version 5.2 Page 22 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 OP38 Good Practice Recommendations That all documentation relating to Health & Safety at the home is kept in a file for easy access. Holyrood House DS0000017852.V298457.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester 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. 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