Inspection on 24/10/05 for Roxholm Hall

This inspection was carried out on 24th October 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Roxholm Hall 30/05/07

Roxholm Hall 05/06/06

Roxholm Hall 14/10/04

Roxholm Hall 20/07/04

Roxholm Hall 19/11/03

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Roxholm Hall Roxholm Sleaford Lincolnshire NG34 8ND Lead Inspector Mr Doug Tunmore Unannounced Inspection 24th October 2005 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Roxholm Hall DS0000002549.V260186.R01.S.doc Version 5.0 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. Roxholm Hall DS0000002549.V260186.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Roxholm Hall Address Roxholm Sleaford Lincolnshire NG34 8ND 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) 01526 832128 Guardian Care Homes (UK) Limited Mrs Kathleen Eglon Care Home 39 Category(ies) of Dementia - over 65 years of age (20), Mental registration, with number disorder, excluding learning disability or of places dementia (1), Old age, not falling within any other category (18) Roxholm Hall DS0000002549.V260186.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20/06/05 Brief Description of the Service: Roxholme Hall is a large Victorian detached property set within 7 acres of its own private grounds in a remote rural area approximately 3 miles from the Market town of Sleaford and between Cranwell and Leasingham. At the time of this inspection the home was registered to provide care for 39 residents in the categories of Dementia, Mental Disorder and Old age. Accommodation is provided on two floors in 34 single and 2 double shared bedrooms all with en-suite facilities. Local facilities can be reached by car and the home has a mini-bus. In addition, staff and a local Dial a Ride service provide transport for residents into Sleaford and to attend other appointments. The grounds are well maintained with parking for staff and visitors. The gardens include a water feature and a large brick dove cote, which is a listed building. The homes Statement of Purpose states that the company aims to provide its residents with a secure, relaxed and homely environment in which their care, wellbeing and comfort are of prime importance. Roxholm Hall DS0000002549.V260186.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and started at 9.30 am. The main method of inspection used was called case tracking, which involved looking at policies and procedures relating to maintaining the safety and general welfare of residents. Residents were spoken to as well as a visitor, the manager and care staff and observations were made of care practices. A partial tour of the home took place. What the service does well: What has improved since the last inspection? What they could do better: No evidence could be found that the home undertakes appropriate fire checks so as to safeguard residents. Resident’s files did not show that either the resident of their representative had read and signed their care plans. The home has not enabled 50 of their care workers to gain NVQ (National Vocational Qualifications in care level 2. The home needs to ensure that care Roxholm Hall DS0000002549.V260186.R01.S.doc Version 5.0 Page 6 workers do not contaminated medication by handling it before giving medicines to residents. 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. Roxholm Hall DS0000002549.V260186.R01.S.doc Version 5.0 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 Roxholm Hall DS0000002549.V260186.R01.S.doc Version 5.0 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): 3 The home undertakes a full care needs assessment of residents prior to admission The home also write to prospective residents informing them that the home can meet their needs or not. EVIDENCE: The homes resident admission forms were seen on file and found to have identified the needs of residents coming into the home. One resident’s file showed that his mobility needs had been transferred from the care needs admission form into his care plan. A risk assessment was also available relating to the residents bedroom and the homes general environment. However, the residents care plan had not been signed by a representative confirming that they had agreed that the plan of care met his needs. A visitor confirmed that she had discussed her mothers care needs prior to admission and signed the care plan. A resident commented that ‘I think in my case they (the care staff) look after me very well’. She continued that they are very friendly and I feel comfortable’. She also received a letter stating that the home could meet her needs. Roxholm Hall DS0000002549.V260186.R01.S.doc Version 5.0 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 the following standard(s): 8&9 There is good care planning in this home, which helps ensure that the general health and welfare of residents is addressed. On the day of the inspection medication was not administered appropriately. EVIDENCE: Individual care plans evidenced that accidents are recorded in the homes’ accident book and in the resident’s daily notes. The home also uses body maps for the mapping of any cuts or abrasions to residents. One accident form was checked through the homes accident procedures and it was found that an abrasion to a resident had been recorded appropriately. Files seen confirmed that health care professionals visit the home when required by the residents. A visitor confirmed that their relatives have seen the GP and other health care specialists and felt that their health care needs were being met. It was seen that a care worker possibly contaminating the medicines given had handled medication for residents. The Boots pharmacist, and the GPs practice pharmacist visited the home on the 12/07/05 to undertake training for care staff in the use of the new medication system. Medication sheets and medication packs and it was found that an accurate record was kept on the day of the inspection. Other issues noted were the appropriate recording of Roxholm Hall DS0000002549.V260186.R01.S.doc Version 5.0 Page 10 prescribed creams, which are entered on the medication sheet, labelled and dated. Also medicines are stored at the recommended temperature and refrigerated medicines are being stored securely. The registered manager stated that the administration of ‘as required’ medicines would be included in the new medication system as soon as possible. Roxholm Hall DS0000002549.V260186.R01.S.doc Version 5.0 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 the following standard(s): These outcomes were not looked at. EVIDENCE: Roxholm Hall DS0000002549.V260186.R01.S.doc Version 5.0 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 the following standard(s): 18 Residents are protected from possible harm by staff attending adult protection awareness training. EVIDENCE: One care worker confirmed that she had undertaken adult abuse protection training in 2004 and would be attending a further course on 31/10/05. She was also aware of what action to take if abusive practices came to her attention. The homes training file showed that adult abuse training had been undertaken on the 05/09/05 and further training is planned for the 31/10/05. A visitor said that she had no concerns about the home and was always made welcome when she visited. Residents seen at lunchtime said that they felt safe in the home and found staff on the whole to be friendly and helpful. Roxholm Hall DS0000002549.V260186.R01.S.doc Version 5.0 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 the following standard(s): 19, 22 & 26 The home is well maintained, with residents having a comfortable environment to live in. Bathing aids are available in appropriate numbers for the people living in this home. The home is clean, comfortable and pleasant. EVIDENCE: The home has a rolling maintenance programme that shows forthcoming maintenance and decoration to be carried out externally and internally at the home. The handyman keeps a log, which showed all maintenance carried out as part of his duties. A tour of the environment found that the home was reasonably well decorated, clean and tidy. Those bedrooms seen had been personalised with photographs and residents own furniture. Residents commented on the attractive grounds in which one resident takes a daily walk weather permitting. Roxholm Hall DS0000002549.V260186.R01.S.doc Version 5.0 Page 14 Risk assessments have been completed on each individual resident relating to their bedroom and the general risk presented by other areas of the home. The home has bathing and toilet facilities on both floors, with all residents having en-suite facilities. These facilities were found to be well maintained and appropriate to the needs of residents. The home also has aids and adaptations including grab rails in bathrooms and toilets as well as raised toilet seats. Since the last inspection the home has purchased a new hoist enabling residents on both floors the opportunity to bath safely without the need for manual handling. One resident commented that she chose this home due to having a large bedroom and en-suite facilities. The home employs two cleaners with a third to be employed in the near future. A partial tour of the home found that it was clean having a pleasant odour. A visitor stated that he had not detected unpleasant odours. A domestic worker commented that she had undertaken training on infection control and manual handling. Roxholm Hall DS0000002549.V260186.R01.S.doc Version 5.0 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 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): 28, 29 & 30 Residents are protected by robust recruitment practices. Residents benefit from a staff team who are well trained and work well together and compliment each other’s skills. National Vocational training levels have not been met. EVIDENCE: Two personnel file seen contained CRB checks (Criminal Record Bureau), references, application forms and interview notes. Care workers have not been given The General Social Care Council Codes of Practice, which sets out their responsibilities as care workers looking after vulnerable adults. The homes training record was seen which showed that, five care workers had NVQ (National Vocational Qualifications) level two, two of these having NVQ three, three workers are to attend NVQ level three training. Statutory training such as fire training, moving and handling are undertaken at this home. Other training undertaken included; food hygiene, first aid, Infection control, medication training and adult protection. One care worker demonstrated a clear understanding of her role and responsibilities. She confirmed that she has undertaken NVQ training levels two and was waiting to attend training to gain level three. The home does not meet the standard for 50 of staff to be trained to NVQ level two by 2005. Roxholm Hall DS0000002549.V260186.R01.S.doc Version 5.0 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 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 & 38 The manager is qualified, competent and of good characters to carryout her duties. Records seen show that residents’ health and general welfare and safety are promoted. The home ensures that that the residents have the opportunity to voice their views and opinions. EVIDENCE: Comments from a member of staff was that the manager ‘is very good and the she gets on really well with her, she (the manager) is very firm but fair and has lots of time for the residents’. A visitor made positive comments stating that she has found the manager ‘very approachable’. During lunch residents also made a number of favourable comments about the positive way in which the home is run and that the manager ‘gets around the home’. The home conducted its last quality assurance questionnaire on 15/03/05. No evidence was available that an analysis of this report had been made available to residents or visitors. Those questionnaires seen showed that in general both Roxholm Hall DS0000002549.V260186.R01.S.doc Version 5.0 Page 17 residents and visitors were very happy with the homes performance. Other audits are also carried out including health and safety and in house audits looking at various functions of the home. The providers representatives visit monthly and provide a written report for the home and The Commission. The minutes of the last residents meeting held on the 01/06/05 and showed that residents are encouraged to voice their views and are actively involved in issues relating to the running of the home. The manager stated that an activities organiser has been appointed and residents meetings would now be undertaken on a monthly basis. There are a range of policies and procedures available in the home relating to fire safety and fire risk assessments. There was no evidence that fire alarm, fire drill and emergency lighting checks have been undertaken. Certificates were available showing that the shaft-lift and bath hoists had been serviced. All wheelchairs seen on the day of the inspection had footplates, which were in use. Roxholm Hall DS0000002549.V260186.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 3 3 x x 3 x x x 3 STAFFING Standard No Score 27 x 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x x x x 2 Roxholm Hall DS0000002549.V260186.R01.S.doc Version 5.0 Page 19 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 Standard OP3 Regulation 15(2)(c ) Requirement The home must ensure that residents care plans are signed either by the resident or their representatives agreeing to the plan of care offered by the home. The home must make arrangements for the handling of medication as per the homes policies and procedures. The home must inform residents and visitors of the outcome of quality assurance audits carried out by the home. The home must ensure that a record of all fire drills and tests are made available in the home. Timescale for action 25/12/05 2 OP9 13(2) 25/12/05 3 OP33 24 25/12/05 4 OP38 23(4)(a) 25/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Roxholm Hall DS0000002549.V260186.R01.S.doc Version 5.0 Page 20 1 2 OP28 OP28 The home should meet the ratio of 50 trained members of care staff with National Vocational training level 2 by 2005. Care workers should be given The General Social Care Council Codes of Practice, which sets out their responsibilities as care workers looking after vulnerable adults Roxholm Hall DS0000002549.V260186.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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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