Inspection on 04/11/05 for Herondale

This inspection was carried out on 4th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 26/06/06

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 4th November 2005 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.V262413.R01.S.doc Version 5.0 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.V262413.R01.S.doc Version 5.0 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.V262413.R01.S.doc Version 5.0 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. 8th June 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. Herondale DS0000027494.V262413.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was unannounced inspection undertaken on the 04th November 2005 over four hours and was carried out as part of a routine inspection plan. On the day of inspection there were twenty-three people staying at the home, three were staying in the rehabilitation unit and an additional ten were visiting the home for Day Care. The atmosphere was friendly and relaxed and residents were seen, sitting in the lounges or their bedrooms, reading, talking, walking around the home and gardens and having a main meal. The inspection took the form of a tour of the premises, individual discussion with five residents, two visitors, five staff and the manager, group discussion with six residents, examination of care plans, records, certificates and the compliance with requirements and recommendations made at the last inspection. What the service does well: What has improved since the last inspection? Residents have benefited from an increase in staffing levels to ensure that their needs are fully met and the redecoration of three bedrooms, replacement of some outer doors and the levelling off of the pavement around the home to make the environment more attractive and safe. Residents are more stimulated and have enjoyed the increase in the number of outings and the use of a reminiscence room that is being created in the newly refurbished bungalow attached to the home and have benefited from the donation of £520 from British Sugar and the purchase of a pressure mattress donated by a resident. Herondale DS0000027494.V262413.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Herondale DS0000027494.V262413.R01.S.doc Version 5.0 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.V262413.R01.S.doc Version 5.0 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): 2, 4, 6 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 available 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. 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. Herondale DS0000027494.V262413.R01.S.doc Version 5.0 Page 9 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.V262413.R01.S.doc Version 5.0 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, 11 Residents were well looked after, they were protected by the medication policies and procedures, their health and personal care needs were met but not all records were completed. EVIDENCE: The information held on each resident had improved, was stored securely, but was not complete. Four individual plans of care were examined and found to contain relevant personal, health and social care information. They also included information on oral, dietary, weight, specialist care, emotional health, personal care needs, moving and handling and risk assessments and daily records but they did not have a photograph or the arrangements at death of each resident. The manager said that she was in the process of having installed on her computer a program that would enable her to take photographs and instantly print. Two requirements were made that a photograph be held of each resident and day care visitor to support proof of identity (repeated) and that the arrangements at death be recorded in the plan of care of each resident to ensure that their wishes are known. Medication policies and procedures were held, staff had undertaken training, medication was stored safely and records demonstrated that medication was Herondale DS0000027494.V262413.R01.S.doc Version 5.0 Page 11 administered and recorded correctly. A recommendation was repeated that due to the constantly changing resident group a photograph of each resident be held with their medication administration records to aid in the identification of each resident and to protect residents. Herondale DS0000027494.V262413.R01.S.doc Version 5.0 Page 12 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 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 the planned activities, entertainment and outings organised at the home and that they had enjoyed the Halloween Party that had taken place last week. The staff spoken to said that since the increase in staffing levels, there was time available in the afternoon and evening for them to carry out activities such as bingo, music and a quiz. 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.V262413.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 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 with the staff and manager any problems, worries and concerns as they happened. 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.V262413.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 23, 24, 25, 26 Further improvements have been made to parts of the home but there are remaining areas that require attention to make the surroundings safe, 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 furnished and decorated to a reasonable standard. 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. The manager said that the reception area was going to be redesigned and refurbished, that new bedroom furniture, easy chairs, lounge chairs and dividers were in the process of being discussed and ordered and that she was confident that this and the replacement of the lounge carpet would all be in place by March 2006. The residents spoken to said that their bedroom would be more comfortable if it contained an easy chair and the day care visitors and Herondale DS0000027494.V262413.R01.S.doc Version 5.0 Page 15 staff member spoken to said that a designated space to enjoy the day care activities was needed. One requirement and three recommendations were repeated and will be met once the refurbishment has taken place and a further requirement was made that the areas in the home where the decoration is worn be redecorated to ensure the home is maintained to a good standard. The health and safety of those visiting, staying and working in the home was not fully protected because the smoke from the lounge used by those who smoked was not extracted from the room and the temperature of the hot water from the tap in the wash basins was not controlled to safe limits. Two requirements have been repeated that an extractor fan is fitted in the lounge used by those that smoke and thermostatic blender valves are fitted to the hot water system. Herondale DS0000027494.V262413.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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 training of staff provided adequate safeguards to protect people living at the home, recruitment checks were carried out but records were incomplete. EVIDENCE: Staffing levels had increased and the staff members spoken to said that morale had improved and that there were enough staff on duty if all posts were covered each shift. The manager said that she was in the process of recruitment and once the two permanent, one annual hours contract and one relief staff members had commenced work the covering of the staff on each shift would be completed. 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. Residents were protected by the recruitment records held and an application form, a contract, a CRB and references were seen to be held at the home but a requirement was repeated that each staff member must have a photograph and a copy of their birth certificate held in their staff file to support identification. The manager said that she was in the process of commencing this once she had compatible I.T. 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, one was doing and ten had completed NVQ3 and that specialist training such as Diabetes and Parkinson’s had been undertaken. Herondale DS0000027494.V262413.R01.S.doc Version 5.0 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): 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. 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. Herondale DS0000027494.V262413.R01.S.doc Version 5.0 Page 18 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 and relevant current certificates were held to ensure that the health and safety of residents is protected. The hot water from the washbasins in the home was found to be very hot and a requirement was repeated that the temperature of the hot water be regulated to “safe” limits to prevent a scalding accident. Herondale DS0000027494.V262413.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 X 3 X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 X 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 x 17 3 18 3 2 x X X 2 2 2 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X 3 3 X 3 2 Herondale DS0000027494.V262413.R01.S.doc Version 5.0 Page 20 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 OP7 Regulation 17.1. a b Sch3 Requirement The registered person must ensure that a photograph is held in the plan of care of each service user. (Previous timescale of 01st September not met) The registered person must ensure that the arrangements at death are recorded for each service user. The registered person must upgrade the worn furniture and carpets in the home. (Repeated date) The registered person must ensure that redecoration is carried out in those areas of the home where the decoration is worn. The registered person must ensure that the temperature of the hot water is regulated. (Previous timescale of 30th September 2005 not met) The registered person must ensure that an extractor fan is provided in the lounge used by those who smoke. (Previous timescale of 31st October DS0000027494.V262413.R01.S.doc Timescale for action 31/12/05 2. OP11 12.3 31/03/06 3. OP19 16.2.c 31/12/05 4. OP19 23.2 31/03/06 5. OP25 13.4.a 31/01/06 6. OP25 13.4.a 31/01/06 Herondale Version 5.0 Page 21 7. OP29 19.1-5 sch2 2005 not met) The registered person must ensure that a photograph and copy of the birth certificate of each staff member is held in their staff file. (Previous timescale of 31st July 2005 not met) 31/12/05 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. 3. 4. Refer to Standard OP9 OP19 OP23 OP24 Good Practice Recommendations It is recommended that a photograph of each resident be held with their medication administration records. Repeated. It is recommended that the main lounge is made more attractive and homely by use of dividers and plants. Repeated. It is recommended that those visiting the home for Day Care have a designated facility. Repeated. It is recommended that an easy chair be put in each bedroom to increase comfort and personal space. Repeated. Herondale DS0000027494.V262413.R01.S.doc Version 5.0 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.V262413.R01.S.doc Version 5.0 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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