Inspection on 01/11/05 for Halsey House

This inspection was carried out on 1st November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Halsey House 20/08/09

Halsey House 02/03/09

Halsey House 21/03/07

Halsey House 09/06/05

Halsey House 27/01/05

Halsey House 01/07/04

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Halsey House 31 Norwich Road Cromer Norfolk NR27 0BA Lead Inspector Mrs Marilyn Fellingham Unannounced Inspection 1st November 2005 09:40 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 Halsey House DS0000040265.V260718.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. Halsey House DS0000040265.V260718.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Halsey House Address 31 Norwich Road Cromer Norfolk NR27 0BA 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) 01263 512178 01263 513630 The Royal British Legion Mrs Mary Teresa Billings Care Home 74 Category(ies) of Old age, not falling within any other category registration, with number (74), Physical disability (1) of places Halsey House DS0000040265.V260718.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th June 2005 Brief Description of the Service: The Royal British Legion is the leading charity safeguarding the welfare of those who have served in the Armed Forces, and their dependants. A major part of its work is to provide short and long term care for ex Service men and women and their dependents. Halsey House is one of the Legions seven nursing/residential care homes. Previously a school, the Home was opened by the Legion after the Second World War and now accommodates 74 Service Users. It is set in delightful gardens and is a short walk from the centre of Cromer on the North Norfolk Coast. Halsey House comprises of an original house that has recently been refurbished, and a large extension. Some of the rooms are en suite but all rooms have access to a wide range of bathrooms and lifting equipment is available when needed. Among the Service Users are those with nursing needs and disabilities. There is 24 hour qualified nursing care, supported by the local medical practice. A licensed bar with pool table is enjoyed by Service Users and their guests, there is also a delightful private chapel that is used for Sunday Services or for quite contemplation. There is an activities co-ordinator who arranges a variety of outings in the local area. The co-ordinator also arranges varied entertainment and assists Service Users who wish to participate in hobbies, art and handicrafts. The Home has a coach and minibus and there are regular shopping trips into Cromer. The Home employs on a part time basis a qualified physiotherapist, occupational therapist, and a hairdresser; other alternative therapies can be arranged on request. Halsey House DS0000040265.V260718.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over five and a quarter hours. Opportunity was taken to tour the premises, look at care records and policies and communicate with several of the sixty-seven residents, staff members, and relatives visiting the home at the time of the inspection. What the service does well: Halsey House is a well-maintained home with many areas inside and out for the service users to utilise. Service users and staff are well supported by an experienced senior team. A friendly and approachable staff group make visitors welcome; this staff group is particularly good at supporting each other and the new manager. There is an excellent care planning system and assessment process in place with appropriate referral to other professional agencies; this allows all levels of staff to have a good working knowledge and understanding of service users needs. Service users indicate that they feel in safe hands. There is a good staff induction system at the home, with continual on going NVQ training. The Royal British Legion understands the significance of investing in staff development. The home demonstrates very good lines of communication with relatives and other professionals. The service users are given many opportunities to go on outings especially during the summer months. Halsey House DS0000040265.V260718.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? 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. Halsey House DS0000040265.V260718.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 Halsey House DS0000040265.V260718.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): 1,2,3,4,5. The admission procedure is good and allows for prospective service users to be given sufficient information to enable them to make an informed choice. The assessment prior to admission to the home is good. EVIDENCE: Examination of records, discussion with senior staff and new residents allowed the Inspector to form the opinion that the process for admission to the home was very good. This information was then used to formulate care plans. Assessment records seen indicate that families are involved if possible with the admission process and history of falls and dependency levels taken into consideration so that no one is admitted unless the home is absolutely sure that all needs can be met. Halsey House DS0000040265.V260718.R01.S.doc Version 5.0 Page 9 All prospective service users are given the home’s statement of purpose and service users guide, these were found to contain all pertinent information regarding admission to the home. Copies of these could also be found in the library along with past inspection reports. The Inspector ascertained from one relative and one new service user that they felt that they had been given enough information prior to admission to the home by the service user. One relative said as soon as she visited the home she realised it was where her father would want to be. Halsey House DS0000040265.V260718.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. The care planning system is exceptionally good and provides all levels of staff clear guidelines for giving care and thus meeting the assessed needs of the service users. Service users health and personal care needs are well attended to. The system for handling and administering medication is good. EVIDENCE: Twenty individual care plans were reviewed, these were clearly set out with evidence of constant review and evaluation. It was noted by the Inspector on various plans where care needs had changed as reported in the daily progress notes and the care plans showed evidence of changes in care. Halsey House DS0000040265.V260718.R01.S.doc Version 5.0 Page 11 Medication records and storage were reviewed and were found to be satisfactory. The MAR charts were accurate and a random audit of medication was found to tally with all medication in stock. Medication for each individual is stored in lockable cupboards in each service user’s room; this has been an immense improvement in the home’s administration of medicines and greatly reduced any risk in association with this process. All those service users who self medicate have been risk assessed to do so and records for this were seen; amendments were also noted when a service user was not deemed safe to do so. Observations made during the inspection showed that staff had an understanding of how to promote service users privacy and dignity. It was also noted that communication between staff and service users was appropriate to the individual needs of the service users. There was evidence in the care notes of liaison with other care professionals this was in addition to monitoring of weight, nutrition and risk to skin integrity. A local GP was visiting at the time of inspection. Halsey House DS0000040265.V260718.R01.S.doc Version 5.0 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. The home offers a full range of options to satisfy service users social and recreational needs. Visitors are made very welcome and visit any time. Those residents who are able exercise control and make choices in relation to their every day activities. EVIDENCE: There is a published programme of activities and outings provided each week; these have been extended to include the weekends also. Staff ensure through working extra hours that the bar is open also at the weekend enabling those who choose to, to have a pre lunch drink on a Saturday. Service users and relatives indicated that they take part in activities and outings if they wish and shopping expeditions are also arranged. The service users have the use of a library that is a very pleasing room to sit in. One service user was playing the piano in the main sitting room, whilst a number of service users were just sitting and listening. Halsey House DS0000040265.V260718.R01.S.doc Version 5.0 Page 13 Many relatives and friends were found to be visiting during the inspection. Members from a quilting club were also visiting and had brought some wonderful bags for use by the residents. Relatives and the service users indicated that they were always made welcome and one daughter, granddaughter and two grandsons were visiting and confirmed this. Halsey House DS0000040265.V260718.R01.S.doc Version 5.0 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): 16,18. Arrangements for dealing with complaints are satisfactory. Service users are protected from abuse. EVIDENCE: Service users and relatives spoken with indicated that they would speak with the manger or with members of the staff team if they had a complaint or concern. Information in relation to complaints is given to each service user, it is also readily available in the home and can be found in the library; it is clear and easy to follow. Records of complaints were reviewed at the inspection and indicated that the action taken resulting from a complaint was within the 28 eight days according to the home’s procedure. Halsey House DS0000040265.V260718.R01.S.doc Version 5.0 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): 19,20, 26. Service users live in a comfortable well-maintained environment. Some rooms are very small. The home is very clean and tidy. EVIDENCE: The home appeared safe and well maintained and is suitable to meet the needs of the service users. The internal and external environment of the home is very pleasant with extensive gardens; the home won ‘Cromer in Bloom’ this year. Some of the individual rooms are very small, however there are plans to rectify this in the very near future. The home was found to be very clean and tidy. Halsey House DS0000040265.V260718.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. Staff are employed in sufficient numbers to adequately meet service users’ needs. Staff have a very good understanding of service users’ support needs. Recruitment procedures are good. EVIDENCE: Duty rosters were examined and the home appeared well supported by skilled staff who were on duty in such numbers to adequately meet the needs of the service users. Designated domestic staff are employed in such numbers to maintain a clean and tidy environment. There are six carers who have level 3 NVQ who are able to support the qualified nurses in their role. Sixty one percent of the carers have level 2 NVQ. Occasionally agency staff are used on night duty but the manager stated that the same ones are used all the time to ensure continuity of care. Recruitment documentation of new staff members was seen, the procedures for recruitment are thorough and all appropriate checks including Criminal Record Bureau enhancements seen. Two references are always sought and the records that were examined confirmed this. Halsey House DS0000040265.V260718.R01.S.doc Version 5.0 Page 17 Halsey House DS0000040265.V260718.R01.S.doc Version 5.0 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,38 The home is managed well. The financial interests of service users are safeguarded by the home’s policies and practices. EVIDENCE: The home has a new manager in post, she had been the deputy and at the time of inspection had only been in the post for a short length of time. It appeared that the service users have already benefited from this appointment and made comments about the manager to support this view. Halsey House DS0000040265.V260718.R01.S.doc Version 5.0 Page 19 The staff are very supportive of the new manager and there appeared to be a much-improved open and transparent atmosphere within the home. A GP who was visiting at the time of the inspection commented to the Inspector that it was a “very well run home, and had no problems with it”. The does not have a quality monitoring system in place yet, the Royal British Legion is formulating a process for this to happen shortly; a requirement is made to ensure this happens. The administrative staff within the home that are employed by the Royal British Legion take care of all the financial affairs, records were seen for this; all service users’ monies are well accounted for. The home seeks to promote the health, safety and the welfare of the service users; this was confirmed through conversations with relatives, service users, staff members and examination of records relevant to safe working practices. All accidents and injuries are reported through the appropriate channels and records were seen for this; however risk assessments do need to be put in place for those service users who have been identified at risk of falling and a recommendation is made. Halsey House DS0000040265.V260718.R01.S.doc Version 5.0 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 4 4 4 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 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 3 1 x 3 x x 3 Halsey House DS0000040265.V260718.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP33 Regulation 24 Requirement The registered person shall establish and maintain a system for reviewing and improving the quality of care. Timescale for action 01/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP38 Good Practice Recommendations It is recommended that risk assessments be put in place for those persons at risk of falling. Halsey House DS0000040265.V260718.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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. Extracts may not be used or reproduced without the express permission of CSCI Halsey House DS0000040265.V260718.R01.S.doc Version 5.0 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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