Inspection on 09/06/05 for Halsey House

This inspection was carried out on 9th June 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 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 21/03/07

Halsey House 01/11/05

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 Marilyn Fellingham Unannounced 9 June 2005 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 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 I55 S40265 Halsey House V231569 090605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Halsey House Address 31 Norwich Road Cromer Norfolk NR27 0BA 01263 512178 Telephone number Fax number Email 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 Royal British Legion Mrs Mary Teresa Billings Care Home 74 Category(ies) of Old age (74) registration, with number Physical disability (1) of places Halsey House I55 S40265 Halsey House V231569 090605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may accommodate up to seventy four (74) service users of the category of old age (OP) and one service users name in the Commissions records who is physically disabled (PD). 2. The total number of service users must not exceed 74. Date of last inspection 27 January 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 Legion’s 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 I55 S40265 Halsey House V231569 090605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over three and a half hours. The manager was present for the inspection and the deputy manager was also present briefly. A tour of the premises took place and the Inspector spoke to three staff members, two relatives, one visitor and eight residents. Many of the residents were visiting a local bird trust sanctuary. What the service does well: What has improved since the last inspection? The home has now increased the activity programme to cover weekends. Meals and menus have much improved since the last inspection. Residents are now given more opportunities to choose what they wish to do. Halsey House I55 S40265 Halsey House V231569 090605 Stage 4.doc Version 1.30 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. Halsey House I55 S40265 Halsey House V231569 090605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Halsey House I55 S40265 Halsey House V231569 090605 Stage 4.doc Version 1.30 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 standard(s) No standards inspected. EVIDENCE: Halsey House I55 S40265 Halsey House V231569 090605 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 The resident’s health, personal and social health care needs are set out in individual plans of care; these plans are easy to read and indicate an excellent review and evaluation of care process. EVIDENCE: Inspection of care plans revealed that the resident’s health care needs were assessed and appropriate care prescribed to meet the assessed needs. The care plans clearly indicated constant review and evaluation of care; they also indicated resident’s involvement. An individual care plan for palliative care using the Liverpool Care Pathway was also inspected, this clearly showed that the individuals needs were being fully met and care changed to meet the constant changes in the resident’s condition. Halsey House I55 S40265 Halsey House V231569 090605 Stage 4.doc Version 1.30 Page 10 Those residents spoken to felt that their needs were being met and that their care was appropriate to their condition. One relative remarked that it was “a very caring home”. Halsey House I55 S40265 Halsey House V231569 090605 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,15 Activities are managed well and meet the expectations of the residents. Meals are also managed well; they are well balanced with choices being available for each meal. The dining room is most pleasant with plenty of room for wheelchair users. EVIDENCE: The home provides a wide range of activities with many outings taking place. The last inspection revealed that the residents felt that there should be activities provided at the weekends and that the bar should also be opened on a weekend day. The home has now extended the activity programme to include the weekends, however the manager stated that the residents have not totally utilised this new programme to its full advantage yet. A programme of full activities is displayed on the main notice board for everyone to see and acknowledge what activities are available. In order for the bar to be opened a bit more, some of the staff operate this in their ‘off duty’ time. Halsey House I55 S40265 Halsey House V231569 090605 Stage 4.doc Version 1.30 Page 12 There is a large activity room in the home that is also used by day visitors to the home: many activities take place during day including use of the reminiscence room. On discussion with the manager it appears the residents do not take advantage of this facility and choose not to participate in the activities provided. However some of the residents felt that the entertainment was marvellous. The menus were inspected and the Inspector spoke with the chef; since the last inspection the menus have changed dramatically to keep in line with residents wishes and steak has also been introduced as a special request. The menus are varied and well balanced and inspection of the complaints book in the dining room revealed that the meals were very satisfactory: the residents spoken with at the time of inspection also confirmed this. The head chef attends the residents meetings so that observations about meals can be addressed on a personal level and for the residents to know that their concerns are being listened to. The dining room is large with an area with facilities for those who need assistance with their meals. The tables are so arranged as to give plenty of room who need assistance and use wheelchairs. Tea dances also take place in this pleasant dining room. The Inspector noted that the comments book housed in the dining room had complementary remarks. Halsey House I55 S40265 Halsey House V231569 090605 Stage 4.doc Version 1.30 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) No standards inspected EVIDENCE: Halsey House I55 S40265 Halsey House V231569 090605 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 Some areas of the home are not entirely suitable for its stated purpose. Although in the main the external environment is tidy and accessible to service users, one area was found to be unsafe. EVIDENCE: The Royal British Legion is well aware of the shortfall in some areas of the home and plans are well in hand to rectify this situation through a major re-build. The external environment was found to be very tidy and the gardens were in good order. Halsey House I55 S40265 Halsey House V231569 090605 Stage 4.doc Version 1.30 Page 15 The grounds are accessible to the residents and the Inspector witnessed a resident walking in the garden: however on further examination of the area the Inspector noted that some outside contractors had left large pipes exposed well above the ground level. An immediate requirement was issued in order to make safe that area; the Manger responded immediately and the area was cordoned off and the contractors notified of the danger. The Inspector noted that some chairs in the smoke room were in need of repair; the Manager informed her that new ones had been ordered. Halsey House I55 S40265 Halsey House V231569 090605 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,30 The deployment of staff is sufficient to meet the needs of the residents; the staffing level is based on the dependency needs of the service users. Staff are given ample opportunities for developing their skills and are competent to do their job. EVIDENCE: It was clear after examination of the duty rosters that there was generally adequate staff on duty to meet the needs of the residents. This does however fluctuate with sickness and annual leave. Dependency levels of the residents are taken into consideration when arranging the duty rosters and notice taken that some of the residents also have nursing needs. The staffing levels correspond with the old Health Authority recommendations. Staff members sometimes feel that there is not sufficient staff on duty to meet the needs of the residents: this could be mainly due to the layout of the home and the distance that staff have to travel within the home. This situation will hopefully improve once the new extension is in use. Training records are in place and were found to take into consideration the types of conditions of service users that were in residence. Halsey House I55 S40265 Halsey House V231569 090605 Stage 4.doc Version 1.30 Page 17 Induction takes place for all new staff members and they are issued with a training programme. All new staff also have a mentor to begin with and are reviewed one month after commencing. Mandatory training takes place, this was confirmed by the staff in discussion with them; they also commented on “how lucky they were in being given many opportunities for training”. Updates in food hygiene, manual handling have taken place, as also has fire training, this was also confirmed by staff members. Qualified nurses have had a number of professional development sessions and they have extended their skills in male catheterisation, use of syringe drivers and tissue viability. Halsey House I55 S40265 Halsey House V231569 090605 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,33,36,38 The home is run in the best interests of the residents. The management are approachable and there is an open inclusive atmosphere. The quality monitoring system could be better managed. The home manages supervision very well. The health, safety and welfare of staff and service users is promoted and protected. Halsey House I55 S40265 Halsey House V231569 090605 Stage 4.doc Version 1.30 Page 19 EVIDENCE: Staff spoken with commented that they worked together well as a team and that they felt they could approach the management team with any concerns. Although some quality surveys have been done they are very limited and no records are kept of this activity; no records are made when concerns have been aired by the residents or how these concerns have been actioned. The staff are well trained in relation to safe working practices and records were seen for these activities. Fire training, food hygiene first aid and control of infection are continually updated. Risk assessments for the environment are in place; these were seen by the inspector. The Inspector noted that all accidents are recorded and that these could be traced back to care plans and revision of care. All accidents are audited and records were seen for this. Halsey House I55 S40265 Halsey House V231569 090605 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 4 8 x 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 2 x x x x x x x STAFFING Standard No Score 27 x 28 3 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x 3 2 x x 3 x 3 Halsey House I55 S40265 Halsey House V231569 090605 Stage 4.doc Version 1.30 Page 21 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 19 Regulation 23 Timescale for action Immediate requirement issued to Immediate make safe the grounds and cordon off area that has two metal pipes sticking up well above ground level. The registered person shall 3 months establish and maintain a system for reviewing and inproving the quality of care. Requirement 2. 33 24 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 Good Practice Recommendations Halsey House I55 S40265 Halsey House V231569 090605 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection 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 I55 S40265 Halsey House V231569 090605 Stage 4.doc Version 1.30 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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