Inspection on 08/06/05 for Herondale

This inspection was carried out on 8th June 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 04/11/05

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 NR13 3RA Lead Inspector Linda Wells Announced 8 June 2005 09:30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Herondale I55 s27494 Herondale v223024 08.06.05 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Herondale Address Bridewell Lane Acle Norwich NR13 3RA 01493 750716 01493 752026 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Age Concern Norfolk Mrs Vivien Moore Care Home 34 Category(ies) of Old Age (34) registration, with number of places Herondale I55 s27494 Herondale v223024 08.06.05 Stage 4.doc Version 1.30 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. Date of last inspection 02 December 2004 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 reablement 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 walk ways. 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 I55 s27494 Herondale v223024 08.06.05 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection undertaken on the 8th June 2005 over seven hours and was carried out as part of a routine inspection plan. Prior to inspection comment cards were received from four residents, two relatives and one healthcare professional and all were satisfied with the care provided at the home. Written comments received said that “it was like home” and that “everything is perfect” . An indication was made that the quality of the food and activities sometimes varied. On the day of inspection there were twenty-five people staying at the home, the atmosphere was friendly and relaxed and residents were seen, sitting in the lounges, watching television, 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 four residents, four staff and the manager, group discussion with two residents, examination of care plans, records, certificates and checking compliance with requirements and recommendations made at the last inspection. What the service does well: The care and attention that is provided for those that stay in the home is good. The six residents spoken to said that they liked staying at the home, they were well looked after, staff treated them with respect and assisted them with all necessary tasks in a kind and considerate manner. They said that their routine could be flexible, the meals were good and that the home was well run and always clean and tidy. The two people spoken to who were visiting the home for day care said that they enjoyed the activities such as doing exercises and that everyone was “very friendly and helpful”. The staff are well trained and the four staff members spoken to said that they enjoyed working at the home, the needs and wishes of residents came first, they were encouraged to promote independence and that they were supported and informed on the needs of each resident. Herondale I55 s27494 Herondale v223024 08.06.05 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: The home could be made more comfortable, attractive and safe for those who visit and stay at the home. Although redecoration has taken place the home is in need of further upgrading in some areas, the records held require a small amount of re-organising and completing, there is a need for a procedure to be followed and health and safety measures are required. As a result the following requirements and recommendations have been made. • The upgrade of the home needs to continue. • The replacement of furniture in the main communal lounge is required. • An extractor fan is required in the lounge used by those that smoke. • Adequate staffing levels must be in place. • Copies of staff personal information, CRB, references, proof of identity and a photograph of each staff member must be held in the home. • Staff training records must be held in their staff file. • The information held must be stored in the individual plan of care of each resident and day care visitor. • Up to date risk assessments must be stored in the individual plan of care of each resident and day care visitor. • Correct medication records must be held. • Valves must be fitted to the washbasins to control the temperature of the hot water to “safe” levels. • A photograph of each resident must be held. • Pictures on the walls of the walkways would make the home more homely. • An easy chair in each bedroom would offer improved personal space. • The main communal lounge would benefit from low-level dividers and plants to create smaller sitting areas that are homely. • Those visiting the home for day care would benefit from a separate identified space. • Some of the dining room tables would benefit from French polishing or other surface attention. Herondale I55 s27494 Herondale v223024 08.06.05 Stage 4.doc Version 1.30 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Herondale I55 s27494 Herondale v223024 08.06.05 Stage 4.doc Version 1.30 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Herondale I55 s27494 Herondale v223024 08.06.05 Stage 4.doc Version 1.30 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3, 5, 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. One resident who was staying at the home for the first time said that she had spent a day at the home and had lunch before deciding to come for a stay. Herondale I55 s27494 Herondale v223024 08.06.05 Stage 4.doc Version 1.30 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 standard(s) 7, 8, 9, 10 Residents were well looked after, their health, personal and social care needs were met but not all records were accurate or stored correctly. EVIDENCE: The information held on each resident was incomplete and not stored in the plan of care. Four individual plans of care were examined and found to contain relevant personal, health and social care information but they did not contain a photograph of the resident and the daily record sheets, risk assessments and summary sheets were held together in a file containing the information of other residents and therefore compromising confidentiality. A photograph must be held of each resident and day care visitor, all records must be kept in the individual plan of care and stored safely. Medication policies were held, staff had undertaken training and medication was stored correctly but the recording procedures did not fully protect residents because the records observed did not equate with the medication actually held in two instances. The manager said that it was possible that one tablet that required cutting in half had disintegrated and that the second was possibly due to a mis-count in medication on admission. A requirement was made that accurate records must be held on the numbers of each medication held, administered and lost due to any mishaps. Herondale I55 s27494 Herondale v223024 08.06.05 Stage 4.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 and 15 The social and creative activities and meals provide daily variation and interest for those visiting and staying at the home. EVIDENCE: There were planned activities that residents said they enjoyed and one resident spoken to said that she had enjoyed the entertainment that had been provided the previous day. The staff spoken to said that outings occurred occasionally, fund raising activities were held at various times of the year and that residents supported the shop and bar in the home. All of the residents and three of the staff said that often staff members were busy and that this resulted in staff having limited time to spend with the more able residents and to organise activities. This issue will be dealt with in standard 27-30. 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 I55 s27494 Herondale v223024 08.06.05 Stage 4.doc Version 1.30 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 standard(s) 16 and 18 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 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 I55 s27494 Herondale v223024 08.06.05 Stage 4.doc Version 1.30 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 standard(s) 19, 20, 21, 24, 25, 26 Recent 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. To create a more attractive, pleasant and homely environment for residents some of the tables in the dining room that were worn and stained were in need of attention to their surfaces and the chairs and the carpet in the communal main lounge required replacing. The appearance of the home could be improved by the use of low-level dividers and plants around and between the main, communal sitting areas and the use of pictures on the walls in the hallways near the treatment room. The residents spoken to said that their bedroom would be more comfortable if it contained an easy chair and the day care visitors and staff member spoken to said that a designated space to enjoy Herondale I55 s27494 Herondale v223024 08.06.05 Stage 4.doc Version 1.30 Page 14 the day care activities was needed. Two requirements and five recommendations have been made. 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 made 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 I55 s27494 Herondale v223024 08.06.05 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29, 30 The training of staff provided adequate safeguards to protect people living at the home. However, recruitment checks were not available. EVIDENCE: The care and social needs of residents were not always fully met and staff members were under pressure at times due to their workload. The residents and staff spoken to all commented that staff were often extremely busy, that residents had to wait a little longer than usual for assistance and that staff had reduced time to spend with residents talking or carrying out activities. The manager said additional staff members were provided where possible and that she had now agreed with staff that the home could not care for more that nine people who required full care needs assistance. A requirement has been made that adequate staffing levels are in place at all times. Residents were not fully protected by the recruitment records held and although the manager said that all recruitment checks had been completed on each staff member no CRB, references, photograph and proof of identity were held at the home. The manager said that they were all stored at the central office with the Human Resources department and a requirement has been made that a copy of the references, photograph, proof of identity and current CRB is held at the home. Residents were cared for by competent staff, training was complete, planned and the records held demonstrated that staff had undertaken induction, foundation, fire safety, NVQ2 and specialist training such as diabetes. Herondale I55 s27494 Herondale v223024 08.06.05 Stage 4.doc Version 1.30 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 36, 37, 38 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. The residents and staff spoken to felt that the home was well run and that the manager was approachable. Staff members are well trained and have regular supervision to ensure that their work practice, commitment and training needs are identified. However, the training records of staff were all stored together in one file and a requirement was made that they are stored in the individual staff file to ensure confidentiality. The staff spoken to all said that they attended meetings held by the manager to gain information about the home and to discuss ideas, plans and concerns. Herondale I55 s27494 Herondale v223024 08.06.05 Stage 4.doc Version 1.30 Page 17 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 made that the temperature of the hot water be regulated to “safe” limits. Herondale I55 s27494 Herondale v223024 08.06.05 Stage 4.doc Version 1.30 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 2 2 3 3 x 2 2 3 STAFFING Standard No Score 27 2 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x 3 3 x x 3 2 2 Herondale I55 s27494 Herondale v223024 08.06.05 Stage 4.doc Version 1.30 Page 19 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 OP7 Regulation 17.1.a b Requirement The registered person must ensure that the information held on each resident is stored in their individual plan of care. The registered person must ensure that a photograph of each resident is held in their plan of care. The registered person must ensure that up to date risk assessments are held in the plan of care of each resident. The registered person must ensure that the records held for medication are accurate and correcly recorded. The registered person must upgrade the worn furniture and carpets in the home. REPEATED The registered person must ensure that the risk assessments held are stored in the individual plan of care of each resident. The registered person must ensure that the temperature of the hot water is regulated. The registered person must ensure that an extractor fan is provided in the lounge used by those who smoke. The registered person must Timescale for action 31st August 2005 1st September 2005 30th September 2005 31st July 2005 and ongoing. 31st December 2005 31st July 2005 30th September 2005 31st October 2005 31st July Page 20 2. OP7 17.1. a b schedule 3 13.4.a-c 3. OP7 4. OP9 13.2 5. 6. OP19 OP20 16.2.c 17.1 7. 8. OP25 OP25 13.4.a 13.4.a 9. OP27 18.1.a Herondale I55 s27494 Herondale v223024 08.06.05 Stage 4.doc Version 1.30 10. OP29 19.1-5 schedule 2 11. OP37 17.2 schedule 4 ensure that adequate staffing levels are in place at all times. The registered person must ensure that all recruitment and proof of identifty checks are carried out and copies held in the file of each staff member and held in the home. The registered person must ensure that staff training records are stored in the individual staff file. 2005 and ongoing 31st July 2005 31st July 2005 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. 5. 6. Refer to Standard OP9 OP19 OP19 OP19 OP20 OP24 Good Practice Recommendations It is recommended that a photograph of each resident be kept with their medication administration records. It is recommended that the main lounge is made more attractive and homely by use of dividers and plants. It is recommended that the walls of the walk ways are made more interesting by the use of pictures. It is recommended that the tables in the dining room are polished to improve the overall look. It is recommended that those visiting the home for day care have a designated facility. It is recommended that an easy chair be put in each bedroom to increase comfort and personal space. Herondale I55 s27494 Herondale v223024 08.06.05 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection 3rd Floor - Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Herondale I55 s27494 Herondale v223024 08.06.05 Stage 4.doc Version 1.30 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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