Inspection on 05/06/06 for Roxholm Hall

This inspection was carried out on 5th June 2006.

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 30/05/07

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 Key Unannounced Inspection 5th June 2006 08:25 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.V297792.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. Roxholm Hall DS0000002549.V297792.R01.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 www.guardian-care.com 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.V297792.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th October 2005 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 shaft lift serves accommodation on the first floor. There are both lounge and dining rooms on each floor. On the day of the inspection there were 36 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 5/6/2006 ranged from £335 to £439 per week. Extras are for hairdressing which range from £4 to £25, chiropody £7.50, toiletries, personal newspapers and magazines. Roxholm Hall DS0000002549.V297792.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and started at 8.25 am. It was undertaken using a review of all the information available to the inspector regarding our service history about Roxholm Hall. It took place over six hours. The inspector spoke to 12 residents, 2 visitors, a visiting social worker, 8 members of staff and the manager. The main method was called “case tracking”. This involved selecting two residents and tracking the care they received through the checking of records, discussion with them, the care staff and observation of how staff responded to their needs and that of the other residents. What the service does well: What has improved since the last inspection? There is a maintenance programme identified and since the last inspection 4 bedrooms have been redecorated, the ground and first floor dining rooms have been repainted, as have the kitchen, a bathroom and smoker’s room. The number of care staff who have achieved a qualification in care (NVQ) or studying for this has increased. Roxholm Hall DS0000002549.V297792.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Roxholm Hall DS0000002549.V297792.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 Roxholm Hall DS0000002549.V297792.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 and 6 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. The manager undertakes a full care needs assessment of residents before people are admitted to the home. The manager then writes to prospective residents informing them that the home can meet their needs. People coming into the home make an informed decision whether they wish to come in to the home or not. EVIDENCE: Each person receives information about the home in the form of a “welcome pack”, which includes a service user’s guide. This is in the process of being reviewed. Each person is assessed before they enter the home and written confirmation is sent to them to confirm that based on this assessment the home is able to meet their needs. This was confirmed by examining a file and discussion with a resident and their family. Roxholm Hall DS0000002549.V297792.R01.S.doc Version 5.2 Page 9 One resident commented, “I was visited by the manager before I came into the home and received an assessment and information about the home”. Each person receives written terms and conditions. The home does not provide intermediate care. Roxholm Hall DS0000002549.V297792.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 and 10 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. There is good, clear care planning in this home, which helps ensure that the general health and welfare of residents is addressed. Medication administration has improved and is now administered safely. EVIDENCE: Each person had a care plan outlining their needs. Care records were detailed, up to date and showed evidence of being reviewed and made with the resident’s involvement wherever possible. Care records included a detailed assessment, social care profile, risk assessment, nutritional, continence assessments and daily records. The home also uses body maps for the mapping of any cuts or abrasions to residents. Files seen confirmed that health care professionals visit the home when required by the residents. Roxholm Hall DS0000002549.V297792.R01.S.doc Version 5.2 Page 11 All senior care assistants responsible for the administration of medication have received training on the safe administration of medication. Medication was seen to be safely administered. Residents felt that the staff respected their privacy and dignity and staff were seen to knock on doors before entering and speak quietly and sensitively to residents. A visitor commented, “I visit every day and find the staff so friendly and caring and supportive”. Roxholm Hall DS0000002549.V297792.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 and 15 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. A wide range of social activities are available to provide stimulation and interest for people living in this home. Meals provided are nutritious, balanced and offer a varied diet. Visitors are made to feel welcome and supported and can visit whenever they wish to do so. EVIDENCE: All care records outlined what the residents liked to do and their interests. There are garden areas surrounding the home. An activities programme for June 2006 was displayed on the notice board at the entrance to the home. Activities planned included a garden party. Activities are provided by an activities organiser who provides 20 hours a week. These activities have been reviewed as a result of a recent survey in January 2006. The manager has also agreed to review the activities provided particularly for people who have a dementia and will arrange for the person to be trained in these aspects. There was quiet relaxing music being played in the entrance to the home. No resident showed any form of distress and staff sat with them. Roxholm Hall DS0000002549.V297792.R01.S.doc Version 5.2 Page 13 Residents were offered a choice of well-balanced and wholesome meals and commented positively on their enjoyment of the food provided. Comments were, “the food is very good” and “I have had an enjoyable breakfast.” A visitor commented, “”I have eaten here with my mother and have found the food very good”. Roxholm Hall DS0000002549.V297792.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 and 18 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. People living in the home can express their views regarding the care and know that their concerns are taken seriously. There are systems in place to ensure that residents are safe as a result of abuse training for staff. EVIDENCE: Each person receives a copy of the complaints procedure in their welcome pack when they come into the home. This is also displayed on the wall in the entrance to the home. The manager and CSCI has received one complaint in March 2006,which continues to be investigated by the manager. Records examined showed that the manager was taking all issues of the complaint seriously. None of the residents or visitors had any complaints and felt they could approach staff if they had any worries. As part of their induction all staff receive training on abuse prevention. A member of staff showed knowledge about what constituted abuse and what they should do if abuse was suspected. Roxholm Hall DS0000002549.V297792.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, 24 and 26 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. The home is well maintained, with residents having a comfortable environment to live in. The home is clean, comfortable and safe. EVIDENCE: Residents who spoke to the inspector said how satisfied they were with decoration and cleanliness of the home. They all spoke of how they liked their bedrooms. There are also attractive, colourful, accessible garden and patio areas. Those bedrooms seen had been personalised with photographs, personal mementoes and resident’s own furniture. It was noted that a number of bedrooms on the ground floor were affected by noise from the dining room on the first floor. This was discussed with the manager who agreed to carry out an audit of bedrooms to see whether the noise could be reduced. Roxholm Hall DS0000002549.V297792.R01.S.doc Version 5.2 Page 16 The home has also experienced heating problems since the last inspection in January and February 2006. All these issues were addressed promptly and CSCI kept informed. The manager acknowledged the heating system is old but is now serviced every 3 months and the system monitored. There was no evidence to show that any resident was at risk. The home has a rolling maintenance programme that shows forthcoming maintenance and decoration to be carried out externally and internally at the home. . This showed that 3 to 4 bedrooms were redecorated each month. The recent survey of residents showed that 75 felt the home needed redecorating. This issue is being addressed by the manager and the owners. 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. There are separate staff employed for cleaning and laundry. The manager explained that an additional commercial washing machine is to be purchased in the future to compliment the existing commercial washing machine and commercial tumble dryer. Residents commented “I always find the home clean”. A partial tour of the home found that it was clean with no unpleasant odours. Roxholm Hall DS0000002549.V297792.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, 29 and 30 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. 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. EVIDENCE: None of the residents expressed any worries about the level or availability of staff. During the inspection staff were seen to attend to residents promptly. Residents commented, “I have never met such kind staff”, “staff are very kind and helpful” and “the staff are very good and friendly”. Records of 2 personal files examined showed that staff had been correctly recruited with checks by the CRB (Criminal Record Bureau), references, application forms and interview notes. Staff also received a supported induction. Care workers are now given a copy of the General Social Care Council’s Codes of Practice, which sets out their responsibilities as care workers looking after vulnerable adults. The homes training record was seen which showed that, 6 care workers had NVQ (National Vocational Qualifications) level two, and a further 6 were working towards this. The manager is also arranging for a further 5 staff to study for this qualification in the future. Therefore 50 of staff have either achieved this qualification or are working towards. Roxholm Hall DS0000002549.V297792.R01.S.doc Version 5.2 Page 18 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. Comments from the staff were, “I have time to care for these people”, “I received a very detailed induction”, and “I start my NVQ this month”. Roxholm Hall DS0000002549.V297792.R01.S.doc Version 5.2 Page 19 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 and 38 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. The home is lead by an experienced and committed manager. This has lead to a confident, supported and trained staff team. People living in the home are confident in the staff and management of the home and are consulted about changes. EVIDENCE: The registered manager who is a registered nurse has extensive nursing and management experience and is studying for a recognised management qualification. Comments from visitors were, “I have confidence in the staff and the manager, if I have any issues I feel I can discuss them openly with them” and “I feel the staff are meeting my mother’s needs”. Roxholm Hall DS0000002549.V297792.R01.S.doc Version 5.2 Page 20 Staff commented, “the manager is very approachable and supportive”, “it is fantastic” and “the manager is very good”. The administrator and the manager on request handle resident’s monies. Where this takes place detailed records are kept together with receipts and signatures. The records are also checked every month. Records examined showed they were well maintained. The home carried out its last quality assurance survey in January 2006. Thirty nine questionnaires were sent out and 38 returned. The manager carried out a detailed analysis of comments received and the outcome was displayed on the notice board in the monthly newsletter and a copy given to each person. Most of the comments were very positive but aspects of activities and decoration are to be addressed by the manager. The manager also carries out internal audits for care plans. medication, accident s and the kitchen as well as health and safety. A representative of the owners makes unannounced monitoring visits to the home and a written report is sent to The Commission. There are a range of policies and procedures including equality and diversity available and a detailed health and safety policy. Roxholm Hall DS0000002549.V297792.R01.S.doc Version 5.2 Page 21 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 x 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 3 x x x x 3 x 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 x 3 x 3 x x 3 Roxholm Hall DS0000002549.V297792.R01.S.doc Version 5.2 Page 22 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. Standard Regulation Requirement Timescale for action 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.V297792.R01.S.doc Version 5.2 Page 23 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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