Inspection on 30/11/06 for Halvergate House

This inspection was carried out on 30th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Halvergate House 03/06/08

Halvergate House 23/05/07

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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Halvergate House Nursing & Residential Home 58 Yarmouth Road North Walsham Norfolk NR28 9AU Lead Inspector Kim Patience Unannounced Inspection 30th November 2006 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 Halvergate House DS0000015642.V322165.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.V322165.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) Position Vacant Care Home 50 Category(ies) of Old age, not falling within any other category registration, with number (50), Physical disability (2) of places Halvergate House DS0000015642.V322165.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). Registration of an appropriately qualified and experienced Manager (RGN). 18th May 2006 4. 5. Date of last inspection 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. The care home is located on the outskirts of North Walsham, standing within its own grounds with off road parking. Up to thirty-five people who have been assessed as requiring nursing care are accommodated and up to fifteen people who have been assessed as requiring residential care can also be accommodated. 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. Halvergate House DS0000015642.V322165.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit took approximately 8 hours to complete and was conducted by the lead Regulation inspector and Frances Chatten, Regulation Manager. Lucy Trevarthen, acting manager, Rob Fawcett, homes consultant and Mr Raghu, Company Director were present throughout and available for consultation. Feedback was provided at the close of the inspection. Staff, residents, and relatives were helpful in providing information that contributed to the assessment of the standards. The site visit included a tour of the premises, interviews with staff and residents, two relatives and a visiting chiropodist. Records relating to staff and residents were inspected and observations of interaction between staff and residents were made, in addition to observations of daily life in the home. Other information used to complete the inspection includes an analysis of staffing rotas for a six week period between September and November 2006, the homes own improvement plan, regulation 26 reports, quality assurance reports and copies of residents records taken from the home at recent random inspections. Since the last inspection the Commission has conducted 4 random inspections and the Pharmacist inspector has conducted 3 inspections of the medication arrangements. On the 5th of October 2006 a statutory requirement notice was issued in respect of the medication arrangements, as the home had not resolved the ongoing concerns about the safe administration of medicines. The pharmacist inspector is currently examining records relating to medication to assess whether the home has complied with the notice. At the time of this inspection it is not known if the Commission will take any further action in respect of medication. What the service does well: • • • The home has a core team of staff who have showed great commitment to improving the service. Staff were observed to have a kind, caring approach to residents. The home offers accommodation and facilities of a reasonable/good and constantly improving standard. Halvergate House DS0000015642.V322165.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? Since the last inspection held on the 18/19 May 2006, the home has made significant improvement in key areas, as follows: • • • • • • Information supplied to prospective residents now includes a copy of the terms and conditions of residence and the complaints procedure. Care plans provide clear detailed information about peoples needs and how they should be met. There is a system in place to ensure that care plans are reviewed and updated regularly. Care plan summaries have been introduced to provide clear succinct information to care staff. Care records are more organised and it is easier to extract relevant information. An activities coordinator has been appointed and has developed a programme of activities based on individual hobbies, interests and needs. Meals and mealtimes have improved with the appointment of the new chef. People are offered more choice and are satisfied with the quality of the food. The staff employed to work in the kitchen have been streamlined to improve efficiency and offer continuity to residents. The complaints procedure is now adequately publicised. The standard of cleanliness and hygiene has improved with the appointment of a new housekeeper. The work schedule of care staff has been reorganised and roles redefined, improving overall efficiency. A twilight shift has been introduced 20.00 – 22.00 in order to offer people more choice in respect of the time they wish to go to bed. The home has appointed a training coordinator. The practice of appointing new staff without the appropriate preemployment checks has ceased. Quality assurance systems are now in place and include consultation with all stakeholders. DS0000015642.V322165.R01.S.doc Version 5.2 Page 7 • • • • • • • • • Halvergate House What they could do better: This home has made great progress since the last inspection and now needs to build on what has been achieved in order to make further improvement and sustain those made. • • The home should consider making a copy of the inspection report available to residents and other visitors to the home. The home must continue to ensure that care plans and risk assessments are written where appropriate and those written are regularly reviewed and updated. The home needs to continue to make progress with meeting people social needs. The role of the activities coordinator/trainer must be reassessed as the hours allocated to each role are insufficient. The home should consider ways to display daily menus for residents, which act as a reminder of meal choices. The home must risk assess and cover radiators to protect residents from the possibility of scalding themselves when they are hot. The use of communal toiletries must cease. The home must address the issues of staff deployment and ensure that adequate staff numbers of staff are on duty at all times. Staff supervision must be improved and a plan of regular documented supervision must be introduced. The home must have a registered manager. • • • • • • • • Please contact the provider for advice of actions taken in response to this Halvergate House DS0000015642.V322165.R01.S.doc Version 5.2 Page 8 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.V322165.R01.S.doc Version 5.2 Page 9 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.V322165.R01.S.doc Version 5.2 Page 10 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 quality outcome in this area is good as the home has a clear admissions procedure and residents are enabled to make an informed choice based on information provided. EVIDENCE: All prospective service users are provided with a brochure pack containing a description of the service, the facilities, admissions procedure, a personal history form, complaints procedure and a copy of the terms and conditions of residence. Pre-admission assessments are completed prior to admission to ensure the home can meet the persons needs and there is an invitation to visit the home prior to making a decision to stay. A letter of confirmation is sent, about the homes ability to meet needs and what these care needs are. Halvergate House DS0000015642.V322165.R01.S.doc Version 5.2 Page 11 The brochure does not yet include a copy of the last inspection report and this is recommended. See recommendations. One residents spoken with confirmed that the admissions procedure had been followed and they were provided with adequate information to make a judgement as to whether the home is suitable for them. Halvergate House DS0000015642.V322165.R01.S.doc Version 5.2 Page 12 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 quality outcome in this area is adequate, as the home has successfully improved the standard of their records in relation to residents needs. However, it cannot be said that the medication arrangements are adequate due to the ongoing concerns. EVIDENCE: There have been 4 random inspections since the last key inspection in May 2006 and the home has been given advice and support to make improvements in the area of health and personal care in order to demonstrate that people’s needs are being met. At a random inspection in October 2006, care plan documentation for several residents was copied to enable a full examination of the records and to measure the level of improvement. Halvergate House DS0000015642.V322165.R01.S.doc Version 5.2 Page 13 Since July 2006 the home has commissioned a consultant who has been instrumental in driving positive change. As such, new care plan documentation has been introduced and nurses have been provided with training and support to produce more effective care plans. A care plan summary has been produced and acts as a record of care given. The summary provides care assistants with clear information of what peoples needs are and incorporates their preferences in this respect. The summaries link to full written care plans that provide much more detailed information with regard to each individual need and there is now evidence that residents are involved in the process. Residents and relatives spoken with were aware of the care plans and had been involved in their development. The care plans seen had been updated where necessary and a system of review is in place. The records were generally more organised and the home has purchased new files in which records can be stored more effectively. Care staff spoken with felt there had been significant improvement in the care planning and the information available to them. They felt their role and how they meet people’s needs had become clearer and more organised. Risk assessments are now written and available for care assistants. However, the home needs to continue to make improvements here to ensure that all risks are assessed. For example, the need for cot sides had been identified and a care plan written for the need to use them, but no assessment was written to assess the risk of using the cot side. The homes medication arrangements have been subject to repeat inspections since May 2006 and following a random inspection in September 2006, a statutory requirement notice was issued. A further random inspection in October 2006 showed that concerns in relation to the safe administration of medicines remained. At the time of writing this report the evidence is still being considered and no decision has been made about the action to be taken in response to the concerns. Separate reports relating to the inspection of medication have been produced by the Pharmacist inspector and are available on request. The home has now made an agreement with the local pharmacist that a monitored dosage system will be supplied and it is anticipated that this will be introduced in February 2007. Halvergate House DS0000015642.V322165.R01.S.doc Version 5.2 Page 14 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): 12,14,15 Quality in this outcome area is adequate, as the home has made improvements in the area of activities and meals. However, there needs to be a period of sustained improvement before the quality rating is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection in May 2006 the home has made significant progress in this area. An activities coordinator has been appointed and has a dual role that includes the responsibility for training new staff. The total time allocated to both roles is 30 hours per week and given the amount of work involved in both areas, the home must consider recruiting another person to take on the training role or to act as activities coordinator. See requirements. In respect of activities, the new coordinator has worked very hard to develop individual social care plans and these have now been completed with all residents. Relatives have been involved in the process as much as possible and Halvergate House DS0000015642.V322165.R01.S.doc Version 5.2 Page 15 the personal history information sheet issued with the admissions pack is also beneficial in providing person centred information in this respect. The social care plans contain information relating to peoples interests and hobbies and the coordinator is working towards developing an activities plan that takes this into account. For those that are not able or do not wish to engage in group activities, one to one sessions are arranged where staff spend time with residents and engage in activities such as looking at memorabilia or doing crosswords. One resident spoke of the pleasure she experienced from someone playing scrabble with her. On the day of inspection the home had arranged a knitting session and many residents were looking forward to this. The activities coordinator has invested a lot of time with staff trying to make sure they understand the meaning of activities and how they can be incorporated into everyday routines with residents. This is a positive shift in the culture of care at the home and can only serve to improve people’s quality of life and the job satisfaction gained by staff. The work on activities is still in progress, however, this is a significant improvement on the previous inspection and it is hoped this good work will continue. Mealtimes were assessed again on this occasion as improvements have been made since the last inspection. The chef was available for discussion about the changes made. The new chef has been in post for approximately 4 months and in that time he has made improvements to staffing that makes catering and serving food more efficient and to offer continuity to residents. For example, kitchen staff now work full days and therefore the same people are serving drinks and meals daily as opposed to various kitchen assistants working split shifts. Menus have been redesigned to offer more variety and choice and are currently displayed on the whiteboard in the dining room daily. Residents are asked to select the meal they wish to have from a choice of two options the day before. During the inspection several residents were asked what they were having for lunch and did not know. Although it is recognised that people often find it difficult to retain the information it may be helpful to residents to have a menu of the day on each table to act as a reminder. See recommendations. Residents spoken with were very satisfied with the food provided and it was evident that the chef has an interactive role with residents gaining feedback on the standard of food and information about what people would like to see on Halvergate House DS0000015642.V322165.R01.S.doc Version 5.2 Page 16 the menu. It was also clear that the chef is committed to providing a flexible menu that promotes real choice on a daily basis and is willing to cater for individual needs as far as possible. At the last inspection and subsequent random inspections there has been an issue with the timing of lunch, which seemed to be determined by the time that staff were able to complete the morning routine with residents. This did not appear to be the situation on this occasion and the chef confirmed that improvements had been made with timing in the last two weeks and lunch is now ready at approximately midday. Halvergate House DS0000015642.V322165.R01.S.doc Version 5.2 Page 17 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 adequate, as the home now has a wellpublicised complaints procedure and has improved systems that serve to protect people from abuse. The home must demonstrate a period of sustained improvement before the outcome area can be rated as good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: As reported at the last inspection, the home has a policy and procedure for dealing with complaints. Since the last inspection the procedure has been placed on display in the foyer and a copy is included in the pre-admission information pack. Those residents and relatives spoken with were aware of how to make a complaint. Improvements have been made to recruitment practice, but there are still issues with staff working unsupervised with first POVA clearance only. Adult protection issues are addressed appropriately. Halvergate House DS0000015642.V322165.R01.S.doc Version 5.2 Page 18 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 Quality in this outcome area is adequate, as the home provides fair accommodation and facilities that are of a reasonable standard in some parts and good in others. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On entering the home strong odours were detected. However, given the time of day it is to be expected and the odours faded throughout the morning. A tour of the premises was completed and all areas were found to be clean and tidy. Resident’s rooms were clean, tidy and homely. Halvergate House DS0000015642.V322165.R01.S.doc Version 5.2 Page 19 Since the last inspection the home has appointed a new head housekeeper and the standard of cleanliness has improved. The issues with equipment have now been resolved and all wheelchairs have footplates, which makes them safer to use. Some improvements are still needed in order to make the environment safer. The radiators in the nursing wing are not covered and on the day of inspection were very hot to touch. The home is required to assess the risk of harm and take action to cover or reduce the temperature of the radiators that pose the greatest risk in the first instance, with a longer-term aim to cover all radiators. See requirements. Some areas of the home were poorly lit, although the home appeared to have adequate lighting in place, lights had not been activated making some areas quite dark. The staff need to ensure that all areas are well lit, not only for health and safety reasons, but for the residents who may already have some deterioration in vision. In addition, it is difficult to navigate around the home easily due to the lack of signage directing people to areas of the building and it is recommended that the home consider posting directional signage to assist people with poor memory and recall. See recommendations. Some of the bathrooms contained unnamed toiletries, which could indicate they are for communal use. This does not promote choice and should be stopped. See requirements. Halvergate House DS0000015642.V322165.R01.S.doc Version 5.2 Page 20 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): 27,29,30 Quality in this outcome area is now adequate, as the home has made significant improvement with staffing. However, the home needs to demonstrate further sustained improvement before it can be rated as good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection two further requirements have been made in respect of staffing. It was considered at the random inspections that the number, deployment and management of staff was still inadequate and peoples needs were not being met to an acceptable standard. During this inspection, staff, residents and relatives were spoken with. In addition, the care records were assessed and the staff rotas for a 9-week period were analysed. The home has reorganised the work of staff, allocating care assistants to work in specific parts of the home. The new care plan summaries have been introduced and provide clarity to the routines in accordance with peoples needs and wishes. This has improved efficiency and outcomes for residents. Staff Halvergate House DS0000015642.V322165.R01.S.doc Version 5.2 Page 21 spoken with reported that they are now able to meet people’s needs and the reorganisation of work has been a positive step. Residents and relatives spoken with reported that they were satisfied with the care provided and felt that their needs were met to a reasonable level. However, there were comments that baths did not always happen when promised. Observations of staff and residents showed that staff had positive relationships with residents, demonstrating a kind and caring approach. The home has introduced a twilight shift, providing an extra member of staff between 20.00-22.00 to cover the residential unit. This is another positive step forward and promotes meaningful choice for those people living in the unit who may wish to retire at a later time in the evening. It also provides the flexibility for the home to provide evening entertainment at the wishes of the residents. There has been significant overall improvement in this area, however, there is still improvement to be made. Staff rotas showed for the month of November that staffing levels still frequently fell below the targets set by the home and there were obvious difficulties at times of holidays and sick leave, eleven of the twenty-eight shifts analysed did not meet the homes own target staffing levels. The home must continue with their efforts to recruit a reliable bank of staff to cover at these times and also consider the impact of change on the current staff group. The acting manager was aware that last minute sickness was an issue. For instance, on the afternoon of the inspection the activities were very popular, but much staff time was taken in ferrying people to the activities, leaving little time for people who had not attended and remained in other parts of the home. In addition, at this time two other care staff were engaged in bathing a resident, again decreasing the number of staff available at a busy time. At the time of the inspection, the number of residents living in the home had fallen to 36, therefore the number of staff employed is expected to fluctuate in accordance with these changes. However, this will remain the subject for close scrutiny and the home is expected to continue to make and sustain improvement here. See requirements In relation to training, the home has appointed an activities/training coordinator. As already stated in standard 15, the dual role carries a considerable amount of work and cannot be completed effectively by one Halvergate House DS0000015642.V322165.R01.S.doc Version 5.2 Page 22 person on the limited hours allocated. However, this is still an improvement. See requirements. The training coordinator has completed training to enable her to train in moving and handling and has been exploring other courses to help in delivering more effective in-house training. The home must support training for the trainer, if she is to be effective. The area of training underpins the provision of good quality services and the role of the training coordinator is crucial. The home still does not have a formal training programme, however, the training coordinator is working towards the development of an annual plan. Recruitment practice was assessed on this occasion and found to be in reasonable order. However, the home must refer to the latest guidance on PoVA and Criminal records checks to ensure that staff do not commence employment without following the proper procedures. Staff who do commence prior to a full CRB being completed, must be supervised by a named worker at all times and evidence of this must be documented on the staff members file. Halvergate House DS0000015642.V322165.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,36 Quality in this outcome area is now adequate, as the home can demonstrate that it has systems in place that promote best outcomes for service users. However, there are still improvements to be made in this area before it can be rated good. The home must appoint and register a competent manager. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the inspection in May 2006 the newly appointed manager at that time has left. An application for registration was submitted and the process completed through to the interview, however, at the time of interview in September 2006 there were a significant number of concerns about the Halvergate House DS0000015642.V322165.R01.S.doc Version 5.2 Page 24 management of the home and in particular the ongoing serious issues with medication management. The manager was not able to demonstrate that she was able to manage the home competently and she withdrew her application before a final decision was reached as to her fitness. At the time of this inspection, the quality assurance manager, who will be holding the post full time until such time another manager is appointed, is managing the home. She has been involved in the management of the home for the last 12 months and is familiar with the systems already in place and has contributed to the progress made so far. Therefore, continuity will continue and the disruption to the service will be minimised. The staff interviewed commented favourably on her inputs. The requirement that the home must appoint and register a manager is carried forward. See requirements. The home continues to make improvements to the quality assurance process and as such have produced customer satisfaction surveys. The results have been analysed and published in a report. It is recommended that the home consider introducing a newsletter as it would have a multiple purpose. Staff spoken with thought a newsletter would be beneficial and an effective way of communicating and disseminating information. See recommendations. The home is now producing regulation 26 reports and has appointed a consultant to carryout independent inspections of the service. From these independent inspections, recommendations have been made and the home has responded positively in order to make improvements to the service. Improvements are still needed in staff supervision. Some supervision has taken place, however, nurses have taken on this role without any training or proper guidance. A requirement was made in respect of this at the previous inspection in May 2006 and is carried forward on this occasion. Nurses must be provided with training in order to conduct effective supervision and the home should consider developing documentation that sets out clearly what the purpose of supervision is, an agreement about the frequency and how it will be recorded. All supervision sessions should be documented and retained in the staff member’s personal file. See requirements. Halvergate House DS0000015642.V322165.R01.S.doc Version 5.2 Page 25 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 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X X STAFFING Standard No Score 27 2 28 X 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X X 2 X X Halvergate House DS0000015642.V322165.R01.S.doc Version 5.2 Page 26 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 OP9 Regulatio n 13(2) Requirement The registered person must ensure that all requirements made by the Pharmacist Inspector are complied with by the agreed timescales. This is ongoing. Statutory Notice timescale of 13.10.06. Timescale for action 30/12/06 2. OP19 13(4) 3. 4. OP14 OP31 12(4)(a) 9(1) The registered person is required 31/03/07 to assess the risk of harm to residents posed by hot radiators and take action to minimise or eliminate the risk. The registered person must 31/03/07 cease the use of communal toiletries. 31/03/07 The registered person must ensure that the home is managed by a person fit to do so. This refers to the need to recruit, train and register a manager. This has been a repeat requirement since October 2004. Previous timescale 01/08/06 The registered person must DS0000015642.V322165.R01.S.doc 5. OP36 18(2) 31/01/07 Version 5.2 Page 27 Halvergate House 6. OP27 18(1) 7 OP27 18(1) ensure that all staff are provided with supervision. This is a repeat requirement. Previous timescale 31/10/06. The home must consider employing a second person to take the role of either activities or training coordinator. The home must address the issues of staff deployment to ensure that adequate numbers of staff are on duty at all times. 31/03/07 31/03/07 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. 2. Refer to Standard 1 OP15 Good Practice Recommendations It is recommended that a copy of the inspection report is made available to residents, relatives and staff. It is recommended that the registered person introduce a way of displaying the menu of the day to remind residents of what is on offer. It is recommended that the home consider producing a newsletter in order to improve communication with stakeholders and disseminate information. It is recommended that the home introduces directional signage and sign posting to assist people with poor memory and recall. 4. 5. OP33 OP19 Halvergate House DS0000015642.V322165.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Halvergate House DS0000015642.V322165.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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