Inspection on 21/03/07 for Halsey House

This inspection was carried out on 21st March 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

Halsey House 20/08/09

Halsey House 02/03/09

Halsey House 01/11/05

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 21st March 2007 09:30 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.V334386.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. Halsey House DS0000040265.V334386.R01.S.doc Version 5.2 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 smills@britishlegion.org.uk The Royal British Legion Ms Sally Joyce Mills 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.V334386.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st November 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. The home is undergoing some extension work and enhancement of some of the accommodation. Halsey House DS0000040265.V334386.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over seven and a quarter hours. During the inspection the manager, deputy manager, six members of staff and eight residents. Comment cards were received from sixteen residents and nine from relatives. Where appropriate the views and observations have been included in the report. What the service does well: This home continues to demonstrate some excellent standards in some areas. Excellent standards were found in all aspects of daily life and social activities and the service users are happy with all their lifestyles. Needs assessments were excellent and those newly admitted service users felt that their needs were being met. The service users all state that the staff treat them with respect and that they feel very safe. Meals continue to be very well managed. There is a good training and induction programme in the home with a good percentage of staff holding NVQ level 2 qualifications. A quality assurance system is in place; many aspects of the home are audited regularly. The home is very good at communicating with the service users and keeping them up to date with all matters relating to the home especially the extension developments. Although large the home remains very clean and tidy with no offensive odours. Halsey House DS0000040265.V334386.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Halsey House DS0000040265.V334386.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 Halsey House DS0000040265.V334386.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): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Persons who wish to use the service are thoroughly assessed before admission and receive written confirmation if their needs can be met. EVIDENCE: Case tracking confirmed good pre admission assessment and indicated that thorough assessments had been carried out prior to admission. Letters were sent to the prospective service users to confirm that their needs could be met. New assessment documentation has been put in place and allows for a very full and informative assessment process to take place. Those service users who had been recently admitted said that they felt that the home could meet all their required needs. Halsey House DS0000040265.V334386.R01.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans have shown a deterioration in their monthly evaluations and work is needed to bring them back to the standard that was found at the last inspection. Residents are not wholly protected by the system for managing medication with shortfalls in practice for recording and stock control. Some staff do not understand about the crushing of some forms of medication and that this practice can have an overall effect of the efficacy of the medication. The majority of the service users feel that they are respected and that their privacy is upheld, although confidentiality had been breached in one area. Halsey House DS0000040265.V334386.R01.S.doc Version 5.2 Page 10 EVIDENCE: Five care plans were examined, these were found to be informative and set out the guidelines for care in a concise way that related to the assessed persons need. It was noted that there were gaps in the evaluation of care that had not been reviewed on a monthly basis. Three service users had not had their skin integrity assessed and one resident’s plan indicated that skin integrity had not been assessed since August 2006 when the resident had been assessed as being at risk. Another resident who had been at risk of developing pressure sores had not been assessed since March 2006. There were informative daily notes in place, however these events were not always noted in the plans of care with no evidence of changes in plans of care to meet the new need. Discussion with staff shows that they have good knowledge of needs but the records kept did not always do not do justice to this. Staff have had training in the administration of medication and have procedures to follow; records were seen for this. However there have been to incidents relating to administration of medication that give rise for concern. One resident was given the same medication twice and another received tablets that had been crushed. The manager has since addressed these concerns and the relevant staff have been issued with letters relating to poor practice and also given the NMC guidelines for the administration of medication. The MAR charts were examined of those individuals whose care notes had been inspected; one of these was self-medicating and a risk assessment was in place for this practice and had clear evidence of review. The other MAR charts were found to have many gaps where it was not clear if the prescribed medication had been given or omitted. One MAR chart had fourteen areas where the medication had not been signed for, another had thirteen gaps where the prescribed eye drops had not been accounted for and also had no record of date of opening. Another residents MAR chart had nine gaps where prescribed medication had not been recorded as having been given omitted or refused. A random check of medication revealed that too much Temazepam, Movicol, Panadol and Dihydrocodeine was held in stock. Observations during the visit to the home showed that staff had a clear understanding of promoting the service user’s dignity and privacy; however privacy also includes confidentiality and some information about a resident was displayed on the outside of their door. Halsey House DS0000040265.V334386.R01.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): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home offers a full range of activities to satisfy the service user’s social and recreational needs. Residents maintain contact with family and friends. Residents are enabled to take control over their daily lives and make choices. Residents are enabled to take control over their daily lives and make choices. EVIDENCE: All activities are planned by the activities coordinators and posted in advance on the general notice board. The activity care plans reflect all activities undertaken by the residents and their involvement. The Inspector was asked to attend the resident’s meeting and noted that they were asked for their ideas about following trips out. Halsey House DS0000040265.V334386.R01.S.doc Version 5.2 Page 12 All residents have been given the opportunity to make comments about the activities provided by the home, the results of this survey were seen and the action taken in respect of the results. One resident remarked that there was always lots going on in the home and that they were all very interesting. The home has special dinner evenings when relatives are invited to be present for a small fee; these dinners have proven to be most successful and the conservatory is turned into a dining room with damask table clothes and waitress service. The care plans also indicated that the home had put on special themes for St Patrick’s Day and planning one for St. George’s Day, all including traditional food. A Spanish meal had also been provided that included flamenco dancers. The service users commented on how they all enjoyed these sessions. Meals continue to be well managed with the general consensus that the food was good with one resident commenting that the chef could make anything taste good. The dining room remains a most pleasant room with menus on tables that allow the residents to choose what they want to eat as they are seated at table. Relatives and friends visit regularly and agree that they are always made to feel welcome. Halsey House DS0000040265.V334386.R01.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements for dealing with complaints are satisfactory Service users are protected from abuse. EVIDENCE: A complaints procedure is available to all service users and their relatives. Those relatives visiting the home and service users were all aware of the complaints procedure and felt if they had any concerns they would be quite happy to voice them. One service user stated that they never had anything to be worried about. The record of complaints was seen and the action taken. One was an allegation of theft that was passed on to the police and APU; this was not substantiated and the home is monitoring should another allegation be made. It was noted that all complaints were dealt with, within the 28 days as specified in the home’s procedure for dealing with complaints. Staff records were examined and it was found that all staff have had training in relation to the protection of vulnerable adults and new recruits to the home verified this. Halsey House DS0000040265.V334386.R01.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in an environment that has shown a shortfall in a resident’s safety. Residents live in a clean and well-maintained environment. EVIDENCE: In general the home is safe and well maintained; however one resident had an open electric fire that was considered a hazard as there were no protection to stop them falling onto it. This resident was also risked as being susceptible to falls and the fire posed an added risk to this vulnerable person. The home was found to be very clean and tidy. Although the outside environment is being disrupted because of further developments no obvious hazards were detected and the manager has made sure that this is so. Halsey House DS0000040265.V334386.R01.S.doc Version 5.2 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ needs are met by adequate numbers of staff. Service users are in safe and knowledgeable hands. There is a robust system in place for recruitment. EVIDENCE: Those residents spoken to felt that they were adequately supported by the staff and that they were well cared for; one service user commented that the home was ideal in every way. A number of the comment cards reflected that both residents and relatives were pleased with the care that they received. Halsey House DS0000040265.V334386.R01.S.doc Version 5.2 Page 16 Those members of staff spoken to felt that they had the skills to care for the residents and meet their needs. They also commented that they were continually being offered opportunities to increase their knowledge and the training records confirmed this. New members of staff are given a rigorous induction, records were seen for this and those new members of staff spoken with said that they had received a formal induction that covered all the common induction standards. The home continues to ensure that its carers are trained to at least level 2 NVQ; 72 of the carers have level 2 NVQ 4 are currently undertaking level 2. The duty rosters that were seen reflected that there were always sufficient staff on duty to meet the changing needs of the residents. Staff records were examined of all new recruits; these contained the appropriate checks and proof of staff identity. Halsey House DS0000040265.V334386.R01.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Management arrangements for this home are good and meeting the needs of the service users and staff. EVIDENCE: Those service users and staff spoken with commented favourably about the management of the home. They also commented that the manager’s door was always open and they felt that they could discuss any issues with her. Records were seen to evidence that the system for formal supervision continues and staff confirmed that they were still having sessions and that they felt that they were beneficial. Records for servicing appliances were seen and up to date. Halsey House DS0000040265.V334386.R01.S.doc Version 5.2 Page 18 A system for monitoring all of its services and results of surveys were seen and evidence of action taken in relation to this and the manger needs to be commended for putting this in place whilst waiting for the Legion to provide its own system. Halsey House DS0000040265.V334386.R01.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 X X 4 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X 3 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 3 3 3 3 3 3 Halsey House DS0000040265.V334386.R01.S.doc Version 5.2 Page 20 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 OP7 Regulation 15 Requirement All people using the service must have an up to date, detailed care plan that is reviewed on a monthly basis or more when needs change. When medication is administered to people who use the service it must be recorded clearly and staff must have up to date knowledge of all medication that is prescribed. This will ensure that people receive the correct medicine and the correct levels at all times. The manager must ensure that the people who use the home are free from hazards. Timescale for action 21/05/07 2. OP9 13.2 21/05/07 3. OP19 23 21/05/07 Halsey House DS0000040265.V334386.R01.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 OP9 Good Practice Recommendations The practice of keeping large amounts of medication in stick should be reviewed. Halsey House DS0000040265.V334386.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. 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