Inspection on 12/11/07 for Elaine Herbert House

This inspection was carried out on 12th November 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

Elaine Herbert House 03/01/07

Elaine Herbert House 18/10/05

Elaine Herbert House 25/04/05

Elaine Herbert House 08/11/04

Elaine Herbert House 08/06/04

Elaine Herbert House 20/01/04

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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Elaine Herbert House The Great Hospital Bishopgate Norwich Norfolk NR1 4EL Lead Inspector Mr Pearson Clarke Unannounced Inspection 12th November 2007 10:05 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 Elaine Herbert House DS0000052349.V354986.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. Elaine Herbert House DS0000052349.V354986.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elaine Herbert House Address The Great Hospital Bishopgate Norwich Norfolk NR1 4EL 01603 610066 01603 766093 anne@greathospital.org 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) The Great Hospital Miss Anne Loveday Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Elaine Herbert House DS0000052349.V354986.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Twenty-one (21) older people may be accommodated. Date of last inspection 3rd January 2007 Brief Description of the Service: Elaine Herbert House is a care home offering personal care and accommodation for 21 older people. The service is operated by the Great Hospital Charity and the care home stands within the overall complex of the Great Hospital. The site is located in the city centre of Norwich near to Norwich cathedral. The home has been open for some time, however it is new to registration having previously been exempt by royal charter. The home is purpose built with accommodation on the ground and first floor. Those living at Elaine Herbert house have access to the grounds of the whole site. There are 21 single bedrooms all of which are en-suite. Elaine Herbert House DS0000052349.V354986.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Care services are judged against outcome groups which assess how well a provider delivers outcomes for people using the service. The key inspection of this service has been carried out by using information from previous inspections, information from the providers ,the residents and their relatives, as well as others who work in or visit the home. This has included a recent unannounced visit to the home and this report gives a brief overview of the service and current judgements for each outcome. What the service does well: What has improved since the last inspection? The home has had new flooring laid to the ground floor corridors the stairs and the first floor lounge. Care plans have improved with better social histories being established with residents. One to one activity and stimulation has improved. Elaine Herbert House DS0000052349.V354986.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. The summary of this inspection report can be made available in other formats on request. Elaine Herbert House DS0000052349.V354986.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 Elaine Herbert House DS0000052349.V354986.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 Quality in this outcome area is ( good). That residents benefit from a service which effectively assesses their needs prior to admission and provides them with the information that they need to inform their choices. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the site visit the inspector discussed admission with the service manager, tracked recent admissions to the home and looked at the homes service user guide. As such it was possible to see that the home continues to admit people based on the result of sound assessments and that they make available the necessary information to provide an informed choice. Discussion with two recently admitted people confirmed that they were happy with the process adopted and the approach of the home. Elaine Herbert House DS0000052349.V354986.R01.S.doc Version 5.2 Page 9 Elaine Herbert House DS0000052349.V354986.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is (good). That residents benefit from a well maintained plan of care which helps ensure they receive the help that they need. Peoples healthcare needs are well met and the approach to medication is sound. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Five care plans were inspected on the day of the site visit and were found to be of a good standard. Since last inspected the service has improved the taking of life histories and have amalgamated the social care plan into the main records. Plans contain risk assessment, evidence of review and give a clear picture of how medical and other needs are met. Residents told the inspector that they were well cared for and that it was a good home with staff who respected their dignity and privacy. Inspection of the homes medication management found a sound approach with secure storage and accurate well maintained records, however it was noted that the home is not maintaining records of the temperatures in the storage area and as such a recommendation is made to do Elaine Herbert House DS0000052349.V354986.R01.S.doc Version 5.2 Page 11 this. Once temperatures are recorded it will be possible to see if they remain within acceptable parameters and should this not be the case then action needs to be taken . Elaine Herbert House DS0000052349.V354986.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is ( good). That residents live in a relaxed home where they are able to exercise choice and control over their daily lives. People enjoy good quality food and benefit from stimulation and activity both as a group and individually. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the site visit the inspector spent time speaking to a number of residents all of whom were held positive views about the home , feeling it was a place that they would recommend. All described the atmosphere in the home as relaxed and all felt in control of their lives , being able to exercise choice on a daily basis. Although the home has communal space it is little used with people choosing to live largely within their rooms. Within each room is a list of all the activity that takes place during the month, with something planned for every day. The home has designated staff time for activities and discussion with the staff member concerned showed that much has been achieved to offer individual activity time to people since last year. Elaine Herbert House DS0000052349.V354986.R01.S.doc Version 5.2 Page 13 Elaine Herbert House DS0000052349.V354986.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is ( good). That people benefit from an approach to complaints and safeguarding where any issues are taken seriously and addressed in a thorough manner. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Commission has received no complaints or concerns about the service since last inspected and inspection of the services records during the site visit confirmed that no complaints have been raised directly with the home. The service has satisfactory policy and procedure relating to complaints and safeguarding and this is reinforced through staff training. Elaine Herbert House DS0000052349.V354986.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is ( good). That people benefit from a clean , safe and well maintained home which is suitable for their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the site visit the inspector toured the homes public areas and visited a number of residents in their rooms. From this it was apparent that people still enjoy a clean hygienic and well maintained environment. In the last year new flooring has been laid on the ground floor and stairs and the upstairs lounge has been re carpeted. Residents rooms are personalised with people bringing their own furniture and possessions where possible. The home was warm and appropriately lit on the day. Elaine Herbert House DS0000052349.V354986.R01.S.doc Version 5.2 Page 16 Elaine Herbert House DS0000052349.V354986.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is ( good). That residents benefit from a home where there are well trained staff who are good at their jobs. Staffing levels allow people to receive good quality care and recruitment is thorough and helps protect those living there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the site visit the inspector looked at staff recruitment records and talked to residents, staff and management about the homes staffing. Those spoken to expressed the view that the home has good staff who are trained to do their jobs and are available in sufficient numbers to deliver effective care. During the day staff were observed to be working in a calm , patient and kindly manner. The home currently exceeds government targets for NVQ training and other training is provided on a regular basis. Although there has been some staff turnover during the last year there remains a longstanding and experienced core team , who enjoy their work and told the inspector that they are a good team. Elaine Herbert House DS0000052349.V354986.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 Quality in this outcome area is (good). That the residents benefit from a safe and well managed service which operates in their best interests. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents spoken to during the site visit felt that they lived in a well run home which operated in their best interests. The manager is experienced and has achieved the registered managers award. Staff feel that they are well managed and supported. Since last inspected the service has had a period of time when the manager was absent and it was apparent from discussion on the day that the temporary arrangements in place during that time enabled the home to Elaine Herbert House DS0000052349.V354986.R01.S.doc Version 5.2 Page 19 continue to function in a smooth manner. Previous inspection has identified that great reliance is placed on the registered manager and it remains the inspectors opinion that a more robust management structure would benefit the service allowing for more effective delegation of some management functions. Sample records relating to residents finances were inspected and found to be in order and it was apparent that the service has embraced the recommendation arising from the previous inspection to hold service users monies separately. Results of resident surveys were seen and examples demonstrated as to how they have influenced change an example being in relation to food. Elaine Herbert House DS0000052349.V354986.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 x x 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 x 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 Elaine Herbert House DS0000052349.V354986.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? No 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. 1 Refer to Standard OP9 Good Practice Recommendations That the service maintain a record of temperature in the room used to store medication and should temperatures exceed the desired range take appropriate action to rectify this. Elaine Herbert House DS0000052349.V354986.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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. Extracts may not be used or reproduced without the express permission of CSCI Elaine Herbert House DS0000052349.V354986.R01.S.doc Version 5.2 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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