Inspection on 03/06/08 for Halvergate House

This inspection was carried out on 3rd June 2008.

CSCI found this care home to be providing an Adequate service.

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

Halvergate House 23/05/07

Halvergate House 30/11/06

Halvergate House 18/05/06

Halvergate House 25/08/05

Halvergate House 02/06/05

Halvergate House 10/03/05

Halvergate House 13/10/04

Halvergate House 16/12/03

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Halvergate House Nursing & Residential Home 58 Yarmouth Road North Walsham Norfolk NR28 9AU Lead Inspector Lella Hudson Unannounced Inspection 3rd June 2008 10:00 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 Halvergate House DS0000015642.V366248.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. Halvergate House DS0000015642.V366248.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Halvergate House Address Nursing & Residential Home 58 Yarmouth Road North Walsham Norfolk NR28 9AU 01692 500100 01692 407474 halvergate@eachltd.co.uk www.eachltd.co.uk East Anglia Care Homes Limited 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) Mrs Elizabeth Kalnins Care Home 50 Category(ies) of Dementia (15), Old age, not falling within any registration, with number other category (50), Physical disability (2) of places Halvergate House DS0000015642.V366248.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The home operates only as a Care Home with Nursing. Fifty (50) Older People, not falling into any other category, may be accommodated. Two (2) people who are no younger than 45 years of age, are in need of nursing care due to their physical disabilities and are in need of respite care may be accommodated. The maximum number of persons accommodated should not exceed fifty (50). Fifteen (15) who have dementia may be accommodated. 4. 5. Date of last inspection 23rd May 2007 Brief Description of the Service: Halvergate House is a large period residence that has been adapted and extended over the years to provide accommodation to a maximum of 50 older people who require either nursing or residential care. The care home is located on the outskirts of North Walsham, standing within its own grounds with offroad parking. Qualified nurses are employed to give twenty-four hour cover in the nursing care part of the home. Care staff and additional ancillary staff including chefs and kitchen assistants make up the staff compliment available in the home. In March 2008 the Home became registered for 15 older people with dementia. The total registered number remains at 50. Halvergate House DS0000015642.V366248.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 Star. This means that the people who use this service experience adequate quality outcomes. This report contains information gathered about the Home since the last Inspection in May 2007. It includes information provided by the manager, such as the completed Annual Quality Assurance Assessment (AQAA) and through notifications to the Commission. It also includes information gathered during an unannounced visit to the Home which was carried out on the 3rd June 2008 between 10am and 5.50pm. During the visit we looked around the accommodation, inspected records, spoke to staff, residents and relatives, observed staff supporting residents and also spoke to the Proprietor, Manager and administrator for the Home. There were 35 residents living at the Home at the time of the visit. The Manager said that only 3 of the current residents have dementia. We received 2 completed relatives surveys, 9 residents surveys and 3 staff surveys. These mainly contained positive comments such as: The Home provides “complete care in every way”. “…works very hard to care for patients” “…a very supportive environment” What the service does well: The Home is well managed by a registered Manager who has the right skills and experience and is motivated, enthusiastic and approachable. The residents and staff feel that the Home is well managed in a way which puts the residents’ needs first. There are many ways in which the views of the residents are sought including resident and relatives meetings, questionnaires, regular discussions with residents on a more informal basis. Action is taken to address any issues and residents are kept informed of any changes. Residents enjoy their meals and say that they have a choice. The cooks meet with them to discuss their preferences and to listen to any suggestions. There are also procedures in place to ensure that the nutritional needs of the residents are met as well as individual choices and that residents receive appropriate support at mealtimes if needed. Halvergate House DS0000015642.V366248.R01.S.doc Version 5.2 Page 6 Staff receive good training and support which enables them to carry out their roles more effectively. Staff said that they enjoy the training provided and that it is relevant and helps them to meet the needs of the residents. What has improved since the last inspection? What they could do better: We have identified problems with the management of medication since 2006 and further problems were found during this inspection visit. The Manager has also identified ongoing problems with medication during her monthly audits of the medication system. Although the Manager has taken action to address these issues they still remain. A referral has been made to the Commissions pharmacy Inspector. Halvergate House DS0000015642.V366248.R01.S.doc Version 5.2 Page 7 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. Halvergate House DS0000015642.V366248.R01.S.doc Version 5.2 Page 8 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 Halvergate House DS0000015642.V366248.R01.S.doc Version 5.2 Page 9 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): 3 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The pre-admission assessments provide information for staff so that residents’ needs can be met when they first move into the Home. EVIDENCE: The AQAA states pre-admission assessments are carried out and this was confirmed through looking at two of the residents’ care records. The assessment contains information from the resident, relatives and health/social care professionals wherever possible. The requirement made in the previous report with regard to pre-admission assessments is met. The pre-admission assessments form the basis for the care plans and are added to once the resident moves into the Home and the staff become more familiar with their needs. Staff said that they have access to the information Halvergate House DS0000015642.V366248.R01.S.doc Version 5.2 Page 10 prior to a resident moving into the Home so that they have an understanding of how to meet the residents’ needs once they move in. Halvergate House DS0000015642.V366248.R01.S.doc Version 5.2 Page 11 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 & 10 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The care plans contain information which enables staff to have an understanding of how to meet the residents’ ongoing support needs and the residents feel that they are treated with respect and that their right to privacy is upheld The residents’ health care needs are not fully met as medication is not managed in a way which ensures residents receive medication at appropriate times EVIDENCE: We saw three of the care plans, including the nursing records. These have been improved since the last Inspection and the requirements made at that time with regard to care planning are met. These documents now contain Halvergate House DS0000015642.V366248.R01.S.doc Version 5.2 Page 12 more personalised information about how to meet residents’ needs. The information is written in a more person centred way, for example, one states that the resident likes to have her music on when she gets up in the morning, another states that the resident likes to have a latte rather than tea or coffee. This information is particularly important for those residents who have difficulty with verbal communication. The staff surveys state that they receive adequate information about how to meet the residents needs. Information about how residents communicate is an area which still needs improvement. For example, the care plan for one of the residents who has difficult with communication states that staff should find out from a relative about what words the resident understands. Some staff who we spoke to are aware of some of these key words, but not all were. It would be beneficial for the resident if this information is written down in the care plan as staff discover what is effective so that it is shared with all staff. This is an area which the Manager is aware needs to develop, particularly as more residents with dementia move into the Home. The care plans contain risk assessments with regard to pressure care, falls, moving and handling and nutrition. The care plans are reviewed and updated on a monthly basis by the nurses. As part of the Home’s quality assurance process the Manager reviews a selection of the care plans on a monthly basis and actions arising from this are passed back to the nurses to carry out. The results of the audit recently have shown that there are some areas which are still in need of improvement. For example, there was a lack of a follow up with regard to one of the residents’ health needs. During our look at the care plans it was also noticed that a health care issue had been identified, but that there were no clear records about what action had been taken about this. The care plans relating to the residents’ personal histories and social needs are still in the process of being developed. The activities co-ordinator has now taken on this piece of work and is encouraging care staff to assist with this. Some of the documents contain a lot more information relating to the residents’ social interests and hobbies, for example, one of the residents with communication difficulties has a clear record of activities and hobbies that he used to be interested in. The staff said that this enables them to talk to him about these subjects and that they are able to choose books or television programmes which may interest him. The residents told us that the staff respect their privacy and dignity when assisting them with personal care. One resident said that the staff always “explain things when they are helping me”. The staff were seen to talk to residents in a respectful and kind manner. When staff are assisting a resident with personal care in their bedroom they activate the light on a panel outside the door which notifies other staff that the resident is being assisted. Halvergate House DS0000015642.V366248.R01.S.doc Version 5.2 Page 13 The Manager sent questionnaires to residents in February 2008 as part of the overall quality assurance process. The responses were seen during the visit to the Home and 80 stated that they considered that respect for privacy was “good”. We received two completed relatives surveys and these both indicate that the Home meets the needs of their relative. The staffing levels have improved since the last Inspection and residents said that they don’t have to wait very long when they ring the bell. They said that they are able to receive assistance at times that suit them, such as getting up and going to bed. The AQAA states that staff receive training with regard to equality and diversity within their induction and that the Manager has recently attended a workshop with regard to this issue. The trainer is currently working with the Manager to provide advice about equality and diversity with regard to the review of policies and procedures which is taking place. The staff who spoke to us have an understanding of equality and diversity being the need to provide individualised care. The Manager sent questionnaires to health/social care professionals in October 2007 as part of the overall quality assurance process. The responses were seen during the visit to the Home. Nine of these contained positive responses and the Manager explained the action that was taken in response to the one questionnaire that raised an issue. The system in place for managing residents’ medication was seen during the visit to the Home. The requirements made in the last report with regard to residents who self-medicate being able to do this safely have been met. Residents who self-medicate have their risk assessment reviewed on a monthly and there is evidence that they are involved in this process. They also now have safe storage in their rooms for the medication. However, the requirements with regard to residents receiving medication in line with prescribing instructions and for accurate records to be kept have not been met. Evidence for this was seen during the visit to the Home and had also been identified during the Manager’s monthly audits of medication over the last few months. For example, the Manager’s audit had identified that there were incidents of medication being signed for, but not given during February, March and April 2008. There were also examples of the administration record having not been signed for medication which was presumed to have been given as it was not present in the monitored dosage packs. The last audit the Manager had undertaken had not identified any problems and she was due to undertake another audit during the week of the visit to the Home. Halvergate House DS0000015642.V366248.R01.S.doc Version 5.2 Page 14 We looked at the medication relating to three of the residents and found errors relating to all three. These include the administration record not having been signed, but medication not in the monitored dosage packs so presumed to have been given, one instance of a medication still being in the pack with no record of why it had not been given. Another example was that one of the residents had not been given a prescribed medication for five days with no record of reasons for this. The Manager had left a message for the nurses with regard to this and the medication had started to be given, but there were still no records relating to this. Written evidence was seen of action taken by the Manager to address the problems with medication over the last few months. This includes individual supervision with nurses, written notices for staff, discussions with care staff about the need for nurses not to be disturbed whilst administering medication unless it is an emergency. The Manager has also carried out a review of errors to see whether there is a pattern relating to timing of administration, particular residents or particular nurses. The requirements have been made on several occasions since January 2006. The Pharmacy Inspector had carried out a separate pharmacy Inspection at the time of the last Inspection but was not present during this visit to the Home. However, due to the problems found during the visit a referral to the Pharmacy Inspector has been made. Halvergate House DS0000015642.V366248.R01.S.doc Version 5.2 Page 15 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 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents enjoy the range of activities that are provided within the Home and enjoy their meals and are satisfied with the range of choices offered to them EVIDENCE: The requirement made in the last report about the need for the residents’ social care needs to be assessed has been met as improvements have been made in this area. There is still further work to be carried out and the activities co-ordinator is in the process of ensuring that this work is completed for all residents. The AQAA identified that the activities co-ordinator was looking to recruit volunteers to assist with the provision of activities as this was an area in which the Home needed to improve. This has now been achieved and the activities co-ordinator is now able to merely co-ordinate rather than having to provide all of the activities. She also provides a lot of the training for staff and so was not able to carry out both these roles effectively. She said that there are now Halvergate House DS0000015642.V366248.R01.S.doc Version 5.2 Page 16 three volunteers who regularly work in the Home. One is responsible for talking to residents about their spiritual needs and arranging for visits from various church personnel and for communion to be carried out where needed. Another volunteer is responsible for organising activities such as Bingo, board games and reminiscence sessions whilst another volunteer organises craft sessions. Another improvement is that the care staff now spend time with individual residents during the afternoons. They are responsible for talking to residents about what they might like to do and this ranges from just chatting, reading to them, doing nail care, going for a walk or helping write a letter. The staff said that this does take place on a regular basis and that they are enjoying being able to spend time with residents on a one to one basis. Residents said that they are given the choice about whether they wish to join in with activities or not. Residents said that they really enjoy the opportunity to join in with a range of activities and that this has been a real improvement over the last few months. During the time of our visit to the Home several activities were taking place. For example, the Pets as Therapy dog was visiting, one of the local church leaders was visiting a resident and discussions were going on with the residents involved in the newly formed gardening group. The staff and residents surveys all indicate that there are activities taking place and that this has improved over the last few months. The residents surveys indicate that they have a choice about how they spend their time. The residents said that they enjoy their meals and that they have a choice about what they would like. Relatives also told us that the residents have a choice and that the food looks appetising. Comments such as: “..the food is lovely, we always have a choice, especially if there is something you don’t like” “The food is as good as any hotel we have been to” We spoke to the assistant cook who said that the majority of ingredients are fresh and that there is always fresh vegetables, fruit and meat used from local suppliers. The cooks provide homemade cakes on a daily basis. Information about the residents individual nutritional needs and likes and dislikes are available in the kitchen for the staff to refer to. A nutritional assessment is carried out for each resident and these were seen within the care plans. Additional advice is obtained from the dietician when necessary. We saw that some residents had nutritional supplements or had thickening agents added to food and drink if they had difficulties with swallowing. Residents received appropriate support during the lunchtime meal whilst we were at the Home. Halvergate House DS0000015642.V366248.R01.S.doc Version 5.2 Page 17 Catering staff are employed in sufficient numbers so that care staff and the nurses are not responsible for tasks associated with preparing or clearing up after meals. The responses within the Home’s questionnaires completed by residents state that 73 of responses state that the food is “good” and 27 stated “satisfactory”. The minutes of residents’ meetings show that meals and mealtimes are discussed during these meetings and that the views of the residents are sought by the kitchen staff as they are keen to meet the residents’ individual needs and choices. Halvergate House DS0000015642.V366248.R01.S.doc Version 5.2 Page 18 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 & 18 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents and relatives are confident that their complaints are listened to and acted upon. Staff training provides increased protection for the residents from abuse EVIDENCE: Residents told us that they know who to complain to and that the Manager is good at sorting things out for them if they ever raise any issues with her. They said that they feel comfortable talking to the Manager or to other staff about any concerns. This was confirmed also by a relative who spoke to us. The complaints procedure is displayed around the Home and the Manager is considering the provision of this in alternative formats to make it easier for residents with communication difficulties to understand. This is part of a general review of information which may need to be provided in alternative formats. Both of the residents surveys which we received state that they are aware of the complaints procedure. One states that concerns are always dealt with appropriately and one states that they are “usually” dealt with appropriately. The views in the residents surveys are mixed in response to the question about whether staff listen and act with some stating “sometimes”, some stating “always” and one stating “hardly ever”. Halvergate House DS0000015642.V366248.R01.S.doc Version 5.2 Page 19 Staff who spoke to us have received training with regard to Safeguarding vulnerable adults and were aware of the correct procedure to follow if they were concerned about possible abuse. They are all confident that the Manager would take concerns seriously and deal with them in the appropriate way. The Manager is aware of the appropriate procedure in the event of an allegation being made. Staff said that they receive training within their induction about Safeguarding and some staff have also attended training provided by Social Services. Halvergate House DS0000015642.V366248.R01.S.doc Version 5.2 Page 20 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 & 26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents benefit from living in accommodation which is well maintained and meets their needs. EVIDENCE: The AQAA identified the improvements that have been made to the environment such as radiator covers having been fitted to all radiators. It also identified further improvements such as the bathrooms needing to be more homely. During the visit to the Home we were shown around the Home by the Manager. All areas were clean and there were no offensive odours. The Home employs domestic staff every day of the week, including weekends. A member Halvergate House DS0000015642.V366248.R01.S.doc Version 5.2 Page 21 of staff is also employed to carry out maintenance and gardening jobs. The residents surveys all state that the Home is clean and fresh. In general, all areas of the Home are decorated and furnished to a satisfactory standard. The Manager liases with the Proprietor about the ongoing maintenance, redecoration and refurbishment plans. The accommodation within the Home is varied as the original part of the Home is an old building and the furnishings and decoration are in keeping with this. The extension to the Home is modern and again, is decorated and furnished in keeping with this style. Residents have a choice of lounges and dining areas in which they can spend time as well as their bedrooms. The Home has hoists and other equipment for meeting residents mobility needs. The staff have easy access to gloves, aprons and other hygiene equipment as needed. Halvergate House DS0000015642.V366248.R01.S.doc Version 5.2 Page 22 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 & 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The needs of the residents are met by staff in adequate numbers who receive appropriate training and support to carry out their roles. The recruitment procedures followed by the organisation help ensure residents are protected. EVIDENCE: There has been an increase in the number of staff on duty for each shift since the last Inspection and so the requirement made at that time has been met. Residents and staff said that this is an improvement as it means that staff have additional time to spend with residents when assisting them with personal care as well as with social activities. Residents said that they do not have to wait so long for staff to respond to the call bell. The rotas confirm the information provided by the Manager about the staffing levels for each shift. This was also confirmed through discussions with staff and residents. The usual staffing levels for the current number of residents (35) is for there to be 2 nurses plus 7 carers on duty during the morning and for there to be 2 nurses and 5 carers on duty during the afternoon. The Manager is aware of the need to review this level of staffing if the numbers increase and if the numbers of residents with dementia increases. Halvergate House DS0000015642.V366248.R01.S.doc Version 5.2 Page 23 As well as the numbers of nurses and care staff the Home also employs a number of ancillary staff to carry out domestic, catering, maintenance, gardening and administration tasks. The activities co-ordinator also works full time and also provides some training to staff. The Manager identified within the AQAA the importance of reducing the high staff turnover and this seems to have been achieved. Staff told us that morale is now much higher within the staff team and that they are working better together. They said that the staff turnover has reduced and as a result there are less agency staff working at the Home. The Manager said that there are currently agency staff covering some night shifts as she is currently recruiting night staff. One resident said that staff are “…chatty…kind…explain things….” One of the relatives told us that they had been very anxious about their relative moving into the Home but that she now “…feels confident in the staff. They are all lovely and we are very happy with the care she is receiving”. The residents surveys all, except one, state that the staff treat them well. One survey states “sometimes” in response to this question. We observed staff supporting the residents and they did this in a kind and calm manner. Staff explained to the residents what they were going to do and tried to obtain the views of residents prior to providing support to them. The activities co-ordinator has a dual role which she says she is able to carry out better now that she has recruited several volunteers to assist with the activities and now that care staff are taking on more of this role themselves. She provides all of the induction for new staff and some of the mandatory training. She also liases with the Manager to source additional training which will enable the staff to meet the needs of the residents. Some of the staff have undertaken dementia training as part of the Homes plan to admit residents with dementia. There are plans in place for further training to be provided so that all staff have a basic understanding and that some of the senior staff have a more advanced understanding of meeting the needs of older people with dementia. The staff surveys state that staff receive good induction and ongoing training. A suggestion is made in one of the relatives surveys that staff would benefit from additional training about the needs of residents with learning disabilities. A selection of staff files were seen and these show that the Home has effective recruitment procedures and that appropriate checks are carried out prior to staff working at the Home. One omission was seen but this was rectified immediately. Halvergate House DS0000015642.V366248.R01.S.doc Version 5.2 Page 24 Halvergate House DS0000015642.V366248.R01.S.doc Version 5.2 Page 25 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, 32 ,33, 35, 36 & 38 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents benefit from the management style and leadership of the Manager Residents feel that their views are sought and taken in to account Residents are protected by the health and safety procedures in place within the Home EVIDENCE: The Manager has been in post since March 2007 following a long period of instability with several managers coming and going. The Manager completed her registration with the Commission in September 2007. She is a registered Halvergate House DS0000015642.V366248.R01.S.doc Version 5.2 Page 26 nurse and has undertaken other appropriate training, including training with regard to dementia care. Residents and staff told us that the Manager has made many improvements since she has been at the Home and that she is approachable and fair. They said that they feel comfortable discussing issues with her and that she takes action and keeps them informed about issues. Staff said that staff morale and team work has greatly improved since the Manager has been in post. Some of the comments made about the Manager are as follows: “ she is approachable and fair” “I am happy with her as my manager” “…excellent manager….enthusiastic” The Manager has implemented many systems whereby the views of the residents are sought on a regular basis and action is taken to address any issues or suggestions that they may have. The Manager has implemented regular resident and relatives meetings as well as staff meetings. The minutes of these include the action taken following issues raised at previous meetings. As part of the ongoing quality assurance process residents and health professionals were asked to complete questionnaires about the service provided at the Home. The results of these have been collated and are on display in the reception area of the Home, as is the latest Inspection report. The Manager also carries out monthly audits of a variety of issues such as medication, care plans and accidents with an action plan arising from these. Staff receive regular formal supervision. This takes different forms depending on what role the staff carry out. All staff receive some form of supervision from their line manager but the nurses also have peer support within the team of nurses. Records are kept of supervisions. The Manager receives formal support from the Proprietor as well as more informal support from the Manager of the other Home owned by the company. We looked at a sample of the records kept relating to money being looked after on behalf of residents. The records and receipts matched the cash held. We saw a selection of records relating to health and safety. These show that this is given a high priority and that regular servicing and maintenance of equipment, including fire safety equipment takes place. The Manager said that a full risk assessment has been carried out of the building and that an updated fire risk assessment has just been carried out by an external company. The electrical equipment is not PAT tested but the Proprietor said that he had been advised that a visual check of plugs etc is satisfactory. Halvergate House DS0000015642.V366248.R01.S.doc Version 5.2 Page 27 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 2 9 1 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 3 3 X 3 3 X 3 Halvergate House DS0000015642.V366248.R01.S.doc Version 5.2 Page 28 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. 5. Standard OP9 Regulation Requirement Timescale for action 03/06/08 13.2, 13.4 People who use the service must have medicines given to them by staff in line with prescribed instructions at all times and this is evidenced by safe recordkeeping practice. This is to ensure people receive medicines in the way they are prescribed. This requirement is made for the sixth time since January 2006. A referral has been made to the pharmacy Inspector 13.2, 13.4 People who use the service must have records fully and accurately completed by staff when medicines prescribed for regular administration are not given. This is to protect people’s health and welfare. This requirement is made for the eighth time since January 2006. A referral has been made to the pharmacy Inspector 6. OP9 03/06/08 Halvergate House DS0000015642.V366248.R01.S.doc Version 5.2 Page 29 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Halvergate House DS0000015642.V366248.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Eastern Region Eastern Regional Contact Team CPC1 Capital Park Fulbourn Cambridge, CB21 5XE 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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