Inspection on 30/05/07 for Roxholm Hall

This inspection was carried out on 30th May 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Roxholm Hall 05/06/06

Roxholm Hall 24/10/05

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 Tobias Payne Key Unannounced Inspection 30th May 2007 08:20 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.V338848.R02.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. Roxholm Hall DS0000002549.V338848.R02.S.doc Version 5.2 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 01526 834107 None Guardian Care Homes (UK) Limited vacant 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.V338848.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th July 2006 Brief Description of the Service: Roxholm 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. Roxholm Hall is registered to provide personal 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 ensuite facilities. Stairs and a shaft lift serves accommodation on the first floor. There are both lounge and dining rooms on each floor. On the day of the inspection visit there were 37 people living in the home. 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. The fees at the inspection on the 30/5/2007 ranged from £348 to £485 each week. Extras are for hairdressing which range from £3 to £22, chiropody £7.50, toiletries, personal newspapers and magazines. Information about the home together with the statement of purpose and service user’s guide is available in the reception area of the home. Roxholm Hall DS0000002549.V338848.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection visit was unannounced and started at 8.20 am. It was undertaken using a review of all the information available to the inspector about Roxholm Hall. We spoke with 12 residents, 5 staff and the manager. The main method of inspection was called “case tracking”. This involved selecting 2 residents and tracking the care they received through the checking of records, discussion with them, the care staff and observation of their care. The inspector also examined a pre-inspection questionnaire, which had been completed by the manager. Comment cards were received from 23 residents/visitors. As a result of concerns brought to the commissions attention we carried out an unannounced random inspection on the 24/7/2006. We looked at care records, medication records and staff recruitment files. We also spoke to residents, visitors the manager and staff. These issues were also followed up at this visit. What the service does well: What has improved since the last inspection? What they could do better: The company must ensure that there is adequate heating and ventilation in all areas of the home used by residents as residents/visitors have spoken of the hot temperatures in the hot weather and cold temperatures in the cold Roxholm Hall DS0000002549.V338848.R02.S.doc Version 5.2 Page 6 weather. The company needs to consider providing an additional commercial washing machine for the laundry. 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. The summary of this inspection report can be made available in other formats on request. Roxholm Hall DS0000002549.V338848.R02.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 Roxholm Hall DS0000002549.V338848.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2, 3, 5 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There was information available to enable residents to make a choice as to whether or not to enter the home. People received an assessment, which resulted in their needs being met. EVIDENCE: There was a service user’s guide and statement of purpose available, which had been amended to include information about the new manager for the home. The brochure about the home had also been reviewed. Each person received a welcome booklet, which included the service user’s guide and information about the home. All information about the home was in the reception area of the home. It was bright and welcoming with music playing and 6 residents were sitting in new comfortable lounge chairs. The manager assessed all residents before entering the home and a letter was sent to them to confirm that the home was able to meet their needs. Each person also had terms and conditions and a contract. A comment card stated, my relative “came to the home before she moved in and liked the home very much”. The home did not provide intermediate care. Roxholm Hall DS0000002549.V338848.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and welfare needs of people living in the home were fully met. There are safe medicine practices in the home. EVIDENCE: All residents had care plans, which described their health and welfare needs. Care records included admission details including a photograph for identification purposes, admission details, assessment of daily living activities, personal history, moving handling assessment, risk assessment, care plan and daily report. Records were up to date and had the signatures of the staff member and resident/relative to signify their involvement. Staff responsible for giving medication had received training about the safe administration of medicines and the last pharmacy visit was on the 3/4/2007. There were no concerns. One resident was self medicating and had a lockable drawer. A medication round was observed and staff checked the card, took the medication to the resident and signed the card to show that the resident had received the medication. There were no concerns about the way medication was being administered. Roxholm Hall DS0000002549.V338848.R02.S.doc Version 5.2 Page 10 Throughout the inspection visit staff attended to residents in a calm and relaxed professional manner, knocking on doors before entering and speaking quietly and sensitively to the residents. Residents commented, “staff are very kind and helpful”, “nothing is too much for the staff” and “staff respect my dignity and don’t hurry me”. Roxholm Hall DS0000002549.V338848.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Social activities were varied and provide daily stimulation and interest for people living in the home. Visitors were made to feel welcome. Meals provided were nutritious and varied. EVIDENCE: Activities in the home were provided by an activities person who worked 20 hours a week. There was information about activities, which were to take place throughout the week, information about religious services, the hairdresser and daily menu. This was clearly displayed on notice boards throughout the home. The manager was keen to further to develop the range of activities provided for people with dementia. We saw an activity taking place on the first floor lounge for 11 people with dementia. There was music, resident involvement and the activity person was talking to and encouraging residents. The manager had meetings with residents every month the last meeting took place on the 14/5/2007. The meeting was attended by 22 residents and copies of the minutes were on the notice boards on the ground and first floors. There was a monthly open day for relatives when the manager was available to discuss any issues with relatives between 08.00 and 20.00 hours. Roxholm Hall DS0000002549.V338848.R02.S.doc Version 5.2 Page 12 The home was awarded 4 stars for its catering service from North Kesteven District Council and the last Environmental Health Officer’s inspection was on the 8/8/2006. There were issues for the home to address and this had taken place. The manager and chef acknowledged that there had been problems with the hot water boiler and a new one was on order. There was a set menu but an alternative was available if a resident did not like what was on the menu. The kitchen was clean, tidy, well organised and well stocked with meat, fresh fruit and vegetables. The cook was appropriately dressed and there were clear up to date records of food, menus and food temperatures. Lunch was observed in the dining room with residents served by care staff who wore plastic aprons and served food in a discreet manner. No resident had any complaints about the food and it was well served and residents were not hurried. The menu was displayed on the wall. None of the residents had any complaints about the food. One resident commented, “I had a lovely cooked breakfast today, just the way I liked it”. Roxholm Hall DS0000002549.V338848.R02.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints received were treated properly and residents and visitors knew that any complaints they had to make would be addressed and taken seriously. Staff were recruited correctly to ensure that residents were protected from abuse. EVIDENCE: There was a complaints procedure displayed at the entrance to the home and each person received a copy of the complaints procedure in the service user’s guide inside the welcome booklet. The home had received 2 complaints since the last inspection. The register showed a clear audit trail with a record of the date the complaint was received, what the complaint was about, what action was required, together with an investigation report and letter sent to the complainant following the investigation. Complaints were also monitored. The commission had received a complaint, which lead to a random inspection on the 24/7/2006. There were requirements about care records and accident recording. All these requirements had been addressed at this inspection visit. None of the staff and residents had any complaints about the home and all felt that the manager addressed complaints but comment cards had expressed frustration that the same concerns kept coming up. The manager was keen to address this Staff were correctly recruited. A member of staff confirmed she had been recruited with criminal records bureau check and a well supported induction. Staff knew about abuse and their role and training had been provided for all staff on abuse prevention in 2007. Roxholm Hall DS0000002549.V338848.R02.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20, 25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents lived in clean, well decorated, homely and safe accommodation. Any maintenance was promptly addressed, however heating and ventilation is not adequate for all people in the home. EVIDENCE: The home was clean, tidy, well decorated and odour free throughout. There was a decoration programme but this had been delayed on account of the maintenance person being off sick since July 2006. Essential maintenance had however been provided by other homes in the company. We discussed long term concerns about the central heating, which had been causing problems since 2005. Comment cards stated “the home would be more comfortable if the owner had the central heating attended to which often breaks down leaving no hot water to wash with also unsuitable windows in the dining room, freezing in the winter and not enough fresh air in the hot weather owing to outdated appliances” and it would help if the windows in the older part of the home could be opened. The sashes are no longer working with some of them Roxholm Hall DS0000002549.V338848.R02.S.doc Version 5.2 Page 15 and some windows are sealed permanently due to the outside paintwork” and “some windows are sealed permanently due to the outside paintwork. There is no double glazing in the downstairs sitting and dining room and mother’s bedroom is colder in the winter and hotter in the summer”. The central heating system was serviced on the 19/4/2007 and there were no concerns. The company were also monitoring this situation. As a result of these comments we, accompanied by the manager, went to a number bedrooms and lounges to look at this issue. Not all bedrooms had natural ventilation, as the windows could not open in one bedroom and a number of sash cords were broken. The windows and ventilation and heating therefore needed to be addressed. Since the last inspection many improvements had taken place which had included new arm chairs and foot stools for the lounges, new carpet to the ground floor corridor, new carpets for 10 bedrooms, the dining room painted with new flooring including sound proofing. At the last inspection the manager told us an additional commercial washing machine was to be purchased. At this inspection visit this had not been done and the laundry person explained that when the washing machine broke down she had at times to use the sink. She and the manager felt an additional machine was required. Residents expressed satisfaction with the laundry service and commented on how clean the clothes were. All the residents we spoke with liked the accommodation and said how much they liked their bedrooms. The gardens were very attractive and well maintained. The dining room had doors and a ramp into the extensive gardens with seating areas and bird and wildlife. Roxholm Hall DS0000002549.V338848.R02.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was adequately staffed with employees who were experienced and competent to care for older people. Residents are protected by robust recruitment practices. EVIDENCE: Staff and residents felt there were sufficient staff in the home. The manager monitored dependency and was able to employ more staff where required. There was a wide range of training provided which had included National Vocational Qualifications in care. There were 50 of staff who had or were studying for NVQ. Training had covered fire training, moving and handling, personal safety awareness, safe handling of medication, dementia awareness, adult protection and health and safety. Staff spoke of the benefit they had obtained from the dementia awareness training and how they had learnt to understand behaviours and the residents better. Staff were seen to go about their work in a professional manner. Staff records were well maintained. Staff spoke of receiving a supported and comprehensive induction programme. Following this they completed a Skills for Care common induction standard detailed induction programme. Staff felt there were sufficient levels of staff and felt supported. Roxholm Hall DS0000002549.V338848.R02.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards31, 32, 33, 35, 36 and 37 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was well lead by a competent, well trained and committed manager. This in turn has lead to a confident, supported and trained staff team. Records 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: The manager had been in post since August 2006. She was a registered nurse and her application to be registered manager was being processed by the commission. She had not yet started studying for a management qualification but intended to do so in the future. Roxholm Hall DS0000002549.V338848.R02.S.doc Version 5.2 Page 18 Staff and residents had confidence in the manager. Residents commented, ”if all homes were like this, then we would do well” and “ I am happy here”. Staff commented, “Gill is brilliant and friendly” and “if I have any concern the manager is very supportive and I receive regular supervision”. Staff received formal supervision regularly and spoke of the support received from the manager. There were clear records of this and also of the annual staff appraisals. There were comprehensive quality assurance systems in place. There was a detailed survey sent out to each relative on the 17/2/2007. An analysis was made of the responses and this was also sent out to each person. Where there were particular issues each one was responded to also in a letter from the manager. As well as residents, relatives and staff meetings the manager also carried out monthly audits of health and safety, occupancy, kitchen and medication. There were 6 monthly audits of infection control and a company Quality Assessment covering all areas in the home. There was also a care plan audits 6 weeks. Each member of staff had an individual training record. New policies and procedures were introduced in January 2007. There was a detailed health and safety policy and care manual with emphasis on providing a person centred approach to care and detailed dementia practice guidelines. There was a very detailed policy about equality and diversity, lifestyle and relationships, spiritual care with detailed guidance regarding religious needs and addresses for advice/contact. A resident with poor sight spoke of the “support and guidance offered by staff”. There were no concerns about equality and diversity. Resident’s monies were well maintained and audited by the administrator and regional manager. Records examined were well maintained, available for inspection and up to date. Roxholm Hall DS0000002549.V338848.R02.S.doc Version 5.2 Page 19 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 3 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 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 2 3 x x x X 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 4 X 3 3 3 3 Roxholm Hall DS0000002549.V338848.R02.S.doc Version 5.2 Page 20 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 OP25 Regulation 23(2)(p) Requirement All people living in the home must be able to have windows in areas throughout the home including bedrooms, which open safely and allow fresh air. This will ensure that residents can have natural ventilation. All people living in the home must have adequate heating when it is cold and in hot weather this must be able to be switched off/adjusted to provide a cool temperature. This will ensure that residents are cool during hot weather and warm during the cool weather. Timescale for action 30/07/07 2 OP25 23(2)(p) 30/07/07 Roxholm Hall DS0000002549.V338848.R02.S.doc Version 5.2 Page 21 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 OP26 Good Practice Recommendations To prevent inconvenience to residents in the home when the one commercial washing machine is out of service, an additional commercial washing machine should be provided. Roxholm Hall DS0000002549.V338848.R02.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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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