Inspection on 26/06/06 for Herondale

This inspection was carried out on 26th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Herondale 24/11/08

Herondale 04/11/05

Herondale 08/06/05

Herondale 02/12/04

Herondale 02/08/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Herondale Bridewell Lane Acle Norwich Norfolk NR13 3RA Lead Inspector Linda Wells Unannounced Inspection 26th June 2006 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 Herondale DS0000027494.V301900.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. Herondale DS0000027494.V301900.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Herondale Address Bridewell Lane Acle Norwich Norfolk NR13 3RA 01493 750716 01493 752026 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) Age Concern Norfolk Mrs Vivien Moore Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (34) of places Herondale DS0000027494.V301900.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may from time to time admit a maximum of two service users living in the home aged between 52 and 64 years. 4th November 2005 Date of last inspection Brief Description of the Service: Herondale is a short stay residential care home providing personal care and accommodation for 28 older people and 6 who need help with rehabilitation. It is operated as a short term, respite, care service owned by Norfolk County Council, and managed by Age Concern Norfolk. The home comprises of a single storey building set in its own grounds and can accommodate 34 older people in 22 single rooms and 6-shared rooms. All bedrooms contain a washbasin and there is communal access to four bathrooms and thirteen toilets situated throughout the home, a main lounge in the centre of the home, two smaller lounges, a lounge for the use of those that smoke, a dining room and a shop and bar. One of the wings Swallow Lodge has been established as a re-enablement unit to give support to 6 service users to regain independent living skills, with support from a dedicated staff team. The home has well kept gardens surrounding the property with ample areas to sit, a patio and is designed to provide pleasant designated walkways. There is parking to the side of the property and the home is located in the village of Acle and is sited close to a medical centre, library and local amenities. The manager said that the current cost of staying at Herondale, is £399 a week (which is £57 a night) or as agreed with Social Services under the Service Level Agreement the home has with Social Services. Herondale DS0000027494.V301900.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Care services are judged against outcome groups, which assess how well a provider delivers outcomes for people using the service. The key inspection of this service has been carried out, by using information from previous inspections, information from the providers, the residents and their relatives, as well as others who work in or visit the home. This has included a recent unannounced visit to the home. This report gives a brief overview of the service and the current judgments for each outcome group. What the service does well: What has improved since the last inspection? What they could do better: Most of the requirements and recommendations from the last inspection have been complied with and improvements have been made to ensure the safety of residents and to the records held. Although redecoration and refurbishment have taken place, the home is in need of further upgrading in the main communal area. The manager said that plans had been drawn up to refurbish Herondale DS0000027494.V301900.R01.S.doc Version 5.2 Page 6 the reception area and communal lounge and that once agreements were made with social services on the joint financing of the final stage, the refurbishment would be completed. As a result of the inspection three requirements and two recommendations were made: • • • • • The upgrade of the remaining worn furniture and carpets must be continued to make the home attractive in all areas. (On order). Repeated requirement. The hours allocated for domestic duties be increased to ensure that the home is adequately staffed to maintain the cleanliness of the home at the weekend. The quality assurance survey sent to CSCI includes the views and feedback of staff members to ensure everyone is consulted. (Questionnaire being compiled). It is recommended that low-level dividers and plants be used to create smaller sitting areas in the main communal lounge to make this area more homely for residents. (On order) Repeated recommendation. It is recommended that an identified space be provided for those visiting the home for day care to promote group activities and privacy. Repeated recommendation. 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. Herondale DS0000027494.V301900.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Herondale DS0000027494.V301900.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5, 6 The quality in this outcome area is good. This judgement has been made using the available evidence and including a visit to this service. The written information available about the home is complete and fully enables residents and staff to make a decision on whether the home will meet the needs of anyone wishing to visit or stay there. EVIDENCE: The Statement of Purpose, Service User Guide and Terms and Conditions contract were seen in each bedroom and contained all the relevant information to inform those who wished to visit or stay at the home. Prior to admission to the home an assessment is carried out to ensure that the needs of residents are identified as being able to be met by the home and includes the views of residents, their families and other professionals. An assessment of any additional assistance in the form of rehabilitation exercises and/or life skills are undertaken on those staying in the rehabilitation unit and a program of rehabilitation organised by a Occupational Therapist. Herondale DS0000027494.V301900.R01.S.doc Version 5.2 Page 9 Residents visit and sometimes stay at the home to enable them to make a decision on whether the home will meet their health and social care needs. One resident who was staying at the home for the first time said that she had visited the home with her family before deciding to come for a stay. Herondale DS0000027494.V301900.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11 The quality in this outcome area is good. This judgement has been made using the available evidence and including a visit to this service. Residents were well looked after, they were protected by the medication policies and procedures, their health and personal care needs were met and all records were complete. EVIDENCE: The information held on each resident had improved, was stored securely, and was complete. Four individual plans of care were examined and found to contain relevant personal, health and social care information, photograph, oral, dietary, weight, specialist care, emotional health, wishes at death, personal care needs, moving and handling and risk assessments and daily records. Medication policies and procedures were held, staff had undertaken training, medication was stored safely and improved records demonstrated that a photograph of each resident was held with their medication records and that medication was administered and recorded correctly. Herondale DS0000027494.V301900.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 The quality in this outcome area is good. This judgement has been made using the available evidence and including a visit to this service. The social and creative activities and meals provide daily variation and interest for those visiting and staying at the home. EVIDENCE: Residents said they were well cared for, their families and visitors were made welcome and that they were encouraged to make their own choices. They said that they enjoyed and were stimulated by some of the planned activities. A record of daily activities organised by the Day Care Co-ordinator, were seen and the manager said that residents staying at the home could join in. The staff spoken to said that there was not always time available in the day, due to pressure of workload, but that they tried to carry out activities such as bingo, music or a quiz in the early evening. The residents all spoke highly of the meals and said that they enjoyed them. The menus and main meal were observed and seen to be varied, wholesome and balanced and records were kept of the alternative any resident choose to aid in the monitoring of the nutritional health of each resident. Herondale DS0000027494.V301900.R01.S.doc Version 5.2 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17, 18 The quality in this outcome area is good. This judgement has been made using the available evidence and including a visit to this service. The home has an active procedure on the protection of vulnerable adults that protects residents and supports the investigation of any cause for concern. EVIDENCE: No complaints have been received since the last inspection and records were seen to demonstrate that the complaints received in the past had been recorded and dealt with appropriately. The residents visiting and staying in the home all said that they felt able to discuss any problems, worries and concerns, as they happened, with staff members and the manager. They all felt confident that they would be listened to, taken seriously and the appropriate action taken to resolve the problem to the satisfaction of all concerned. The home has an adult protection policy, residents are supported in exercising their legal rights by the use of advocates and staff members have undertaken Adult Abuse training to enable them to recognise, prevent and deal with any potential abuse and protect the people living and working in the home. Herondale DS0000027494.V301900.R01.S.doc Version 5.2 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25,26, The quality in this outcome area is adequate. This judgement has been made using the available evidence and including a visit to this service. Further improvements have been made to parts of the home but there are remaining areas that require attention to make the surroundings attractive and comfortable for the people living and working in the home. EVIDENCE: A tour of the building revealed that the home was clean, odour free and that improvements had been made to all of the bedrooms where furniture had been replaced with matching, high quality furniture, a lockable bedside cupboard and an easy chair. Residents would benefit from a more attractive, pleasant and homely environment if the chairs and the carpet in the communal main lounge were replaced and the appearance of the home could be improved by the use of lowlevel dividers and plants around and between the main, communal sitting areas. Plans and swatches were seen to show that the reception area and communal lounge is going to be redesigned and refurbished, that new lounge Herondale DS0000027494.V301900.R01.S.doc Version 5.2 Page 14 chairs and dividers had been ordered, that the lounge carpet will be replaced and those attending Day Care will have designated facilities. One requirement and two recommendations were repeated and will be met once the refurbishment has taken place. Improvements had been made to the health and safety of those visiting, staying and working in the home by the fitting of an extractor fan in the lounge used by those who smoke and the regulating of the temperature of the hot water from the tap in the wash-basins, to safe limits. Residents, benefit from the increase in specialist equipment that had been provided in the form of an additional stand aid hoist and the provision, in two bedrooms, of an electrical hospital type bed and overhead-tracking hoist to aid in maintaining the independence of residents. Herondale DS0000027494.V301900.R01.S.doc Version 5.2 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 The quality in this outcome area is adequate. This judgement has been made using the available evidence and including a visit to this service. The training of staff provided safeguards to protect people living at the home, recruitment checks were carried out, records were complete but domestic hours at the weekend were poor. EVIDENCE: Staff member spoken to said that they were support by the senior staff and given enough information on each resident. Residents said that their health, care and social needs were met; staff members were competent and aware of their needs. This was found in the discussion with staff and in the records held. The domestic staffing rota revealed that only one member of staff was on duty at the weekend and part of the domestic assistant role at the weekend was to assist in the loading and unloading of the dishwashing machines in the refectory area of the kitchen. This resulted in possible cross infection through staff carrying out cleaning duties in the home and kitchen duties, no domestic staff available to deal with soiled carpets and floors for up to three hours a shift and the cleanliness of the home being reduced. A requirement was made that either the kitchen assistant or domestic staffing levels be increased, at the weekend, to ensure the health and safety of residents. Herondale DS0000027494.V301900.R01.S.doc Version 5.2 Page 16 Residents, were protected by the improved recruitment records held and an application form, a contract, a CRB, proof of identity, birth certificate, photograph and references were held in the file of each staff member. Residents were cared for by competent staff, training was complete, planned and the records held demonstrated that staff had undertaken induction, foundation, fire safety, updated basic training, the target of 50 with NVQ2 had been exceeded, ten had completed NVQ3 and that specialist training such as Dementia had been undertaken. Herondale DS0000027494.V301900.R01.S.doc Version 5.2 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36, 37, 38 The quality in this outcome area is good. This judgement has been made using the available evidence and including a visit to this service. Staff members are supported and supervised, the needs of residents are met and complete systems of record keeping, policies and procedures are held. EVIDENCE: The manager has over twenty years experience of working within the care setting and has an open and inclusive approach that creates a friendly and supportive atmosphere. She has completed the NVQ4 Registered Managers award in Care and the residents and staff spoken to felt that the home was well run and that the manager was approachable. A Quality Assurance system is in place that takes into account the ‘end of stay’ views and feedback of residents, day care visitors, relatives, visitors and other professionals and an action plan of improvements produced. However, a requirement was made that staff members be included and the manager said Herondale DS0000027494.V301900.R01.S.doc Version 5.2 Page 18 that a questionnaire for staff members was in the process of being developed and once used would ensure that everyone is consulted. Residents were protected, by the accounting and financial procedures held in the home and individual records were seen to demonstrate that all debits and credits were recorded for any money held for residents and that it was stored securely. The home has just secured a Service Level Agreement with Social Services that will add to the financial security of the home. Staff members are well trained and have regular supervision to ensure that their work practice, commitment and training needs are identified. The staff members spoken to all said that they attended meetings, held by the manager, to gain information about the home and took part in discussions on suggestions, plans and concerns. Policies and procedures on all aspects of the home were seen and demonstrated that they protected and promoted the rights and best interests of anyone staying at or visiting the home. The servicing and testing of all equipment in the home has been carried out, the hot water system has been regulated to a safe temperature and relevant current certificates were held to ensure that the health and safety of residents is protected. Herondale DS0000027494.V301900.R01.S.doc Version 5.2 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 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 3 18 3 2 3 3 3 2 X 3 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 3 3 3 3 3 Herondale DS0000027494.V301900.R01.S.doc Version 5.2 Page 20 YES 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 OP19 Regulation 16.2.c Requirement The registered person must upgrade the remainder of the worn furniture and carpets in the home. (Previous timescale of 31st December 2005 not fully met) The registered person must ensure that adequate domestic staff members are on duty at the weekend. The registered person must ensure that the views and feedback of staff members is included in the quality assurance report and action plan of improvements produced. Timescale for action 31/12/06 2 OP27 18.1 01/10/06 3. OP33 24.1 31/12/06 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. Herondale Refer to Standard OP19 Good Practice Recommendations It is recommended that the main lounge is made more DS0000027494.V301900.R01.S.doc Version 5.2 Page 21 attractive and homely by use of dividers and plants. Repeated. 2. OP23 It is recommended that those visiting the home for Day Care have a designated facility. Repeated. Herondale DS0000027494.V301900.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: 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 Herondale DS0000027494.V301900.R01.S.doc Version 5.2 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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