Inspection on 12/01/06 for Hethersett Hall

This inspection was carried out on 12th January 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Hethersett Hall 06/02/09

Hethersett Hall 06/08/08

Hethersett Hall 09/11/06

Hethersett Hall 16/06/05

Hethersett Hall 18/11/04

Hethersett Hall 14/06/04

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 Hethersett Hall Hethersett Norwich NR9 3AP Lead Inspector Ruth Hannent Announced Inspection 12th January 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 Hethersett Hall DS0000048257.V269701.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. Hethersett Hall DS0000048257.V269701.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Hethersett Hall Address Hethersett Norwich NR9 3AP 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) 01603 810478 01603 810860 hethersett@barchester.com Barchester Healthcare Homes Limited Mrs Lisa Thomspon-Tullis Care Home 54 Category(ies) of Dementia (10), Old age, not falling within any registration, with number other category (44) of places Hethersett Hall DS0000048257.V269701.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th June 2005 Brief Description of the Service: Hethersett Hall comprises of a late regency manor house with 3 modern extensions. The home has two units, the main hall provides residential accommodation for forty four older people, and the garden house provides residential accommodation for ten older people with dementia. Most of the home consists of two storeys, apart from the garden house. Hethersett Halls accommodation consists of 30 single and 7 shared bedrooms with en-suite facilities, and the Garden House accommodation consists of 6 single and 2 shared bedrooms with en-suite facilities. It is situated on the outskirts of the village of Hethersett, approximately two miles from the A11. Barchester Healthcare owns the home. Hethersett Hall DS0000048257.V269701.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection, which took place over a period of seven hours. Many residents and staff were spoken to throughout the day. Eight residents and seven relatives comment cards were received. The pre inspection questionnaire was discussed. Records seen were care plans, risk assessments, personnel files, logged recordings of fire drills, fire risk assessments and alarm checks, COSHH safety sheets, medication MAR sheets and staff training records. A meal was taken with the residents. A tour of the building took place. What the service does well: What has improved since the last inspection? The Home is about to complete new assisted bathrooms, which enables residents to have a bath near to their room and not have to go to another floor. The laundry area room size has been increased and new equipment purchased. The staff training is developing with more knowledge being gained by staff, especially in dementia care. Hethersett Hall DS0000048257.V269701.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. Hethersett Hall DS0000048257.V269701.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 Hethersett Hall DS0000048257.V269701.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): 3 and 5 The potential resident has their needs assessed as part of the process for suitability within the service that can be provided. The Home actively encourages people to visit and a trial stay is in place to assess the suitability of the service and help the home complete the assessment. EVIDENCE: The Home has an assessment format that is used each time a prospective resident is asking to be considered as a resident at Hethersett Hall. The format seen is able to give a picture of need. The Manager explained that this assessment is only part of the process of ensuring the needs of the individual can be met. The need for a trial stay for both the Home to fully assess the ability to manage the care and for the resident to be sure the Home is suitable for them will give a clearer picture of the needs required. Hethersett Hall DS0000048257.V269701.R01.S.doc Version 5.0 Page 9 A trial period of four weeks is offered with initially a visit to have lunch or meet other residents is offered. On talking to a new resident it was made available that she could visit prior to admission but had preferred her daughter to assess the Home. She is now in the trial four weeks period which she was very clear about and is aware that she can leave after this period if she wishes. Hethersett Hall DS0000048257.V269701.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 and 10 The residents full care needs are recorded but the format to find the information is not helpful. The health care needs of residents are met. The Home has a good procedure in place for dealing with medication but administration recording needs to be improved. Residents are treated with respect and their privacy is upheld. EVIDENCE: Each resident has an individual care plan that at present is written on a format that is repetitive and sometimes difficult to follow. The information is there but needs to be on a clearer format, which the Barchester Healthcare company are developing. In total four care plans were seen in the two areas of the Home where care plans are kept. In the dementia group care plans are beginning to reflect on the strengths of the individual resident enabling the staff to reflect and actively encourage those strengths. These care plans are regularly Hethersett Hall DS0000048257.V269701.R01.S.doc Version 5.0 Page 11 reviewed and the residents who were spoken to in the House new of these documents and were happy with the care provided. Each resident is registered with the local GP and the Community Nurse visits regularly. One resident wrote on the comment card that the GP is not helpful but on talking to many of the other residents they were all very happy with the provision of the local health centre. Clear notes (once found) in the care plan recordings showed monitoring of health requirements such as blood checks and CPN assistance written in detail. Due to the records being difficult to find the Home has developed a quick read A4 sheet of medical history on each resident that can then be sent to any appointment or emergency admissions to hospital. (This A4 sheet was much easier to follow and the Home has received good feedback from the hospital on this way of recording). The Home holds all medication in a locked trolley with MAR charts and a monitored dose system in place. The controlled drug temazepam was correctly recorded with two signatures and the number of 36 on counting was the amount written. On checking the MAR charts it was noted a few gaps on recording especially on prescribed creams. The PRN medication was also not recorded regularly and some not required for a whole month, which highlighted a review on whether it is now needed as a prescription item. (Requirement). Throughout the day staff were observed speaking to residents in a respectful manner. All doors were knocked on before the staff member entered and mail was offered to the residents and only on request by the individual was assistance given with opening the envelopes. (One gentleman often asks for assistance with his mail and on talking with this gentleman it was confirmed that it is only at his request). All residents clothing was smart, clean and tidy. On talking to the staff member in the laundry she takes great pride in seeing residents in their clean wellpressed clothes and gets great job satisfaction from it. Hethersett Hall DS0000048257.V269701.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 and 15 Residents experience a lifestyle that satisfies their expectations. Families and friends are welcomed and residents can take part in the local community. Residents are helped to exercise choice and control over their lives. Meals are enjoyed,wholesome and well balanced but the dining room surroundings are not relaxing. EVIDENCE: The Home has a very active lifestyle with many stimulating ideas put into practice. The Home has two activities organisers with a wide range of activities to meet all tastes. A programme of events was seen on the notice board and two comment cards gave examples of the enjoyed events the home offers. On the afternoon of the inspection a slide show was leading to a lot of conversation among many residents. One person talked of his Sunday visits to the local church and the family trips out. Within the group of residents in the Garden House many and varied forms of stimulation was noted. At least three staff were offering one to one time with Hethersett Hall DS0000048257.V269701.R01.S.doc Version 5.0 Page 13 individuals. Newspapers were out, a jigsaw was being completed, a cuddly toy was being happily cuddled and talked to and a word game was being carried out. All faces were relaxed and when spoken to were smiling and appeared content. Throughout the day visitors were seen coming and going. One gentleman made a point of saying how good the staff were and how they always had time to answer any questions. One daughter visiting said how much her children loved to visit and how welcome they all felt. Residents have the facilities in their rooms to sit visitors in comfort or use the lounges. (The Garden House at present does not have many areas to entertain visitors but the Manager is hopefully addressing this shortly as new building works are planned. The Home does not deal with finances of individual residents but will assist the person to remain in control of their affairs if requested. (One person said he needed guidance with some finance and the Home helped him find the correct expert to help him). Many of the rooms held residents own belongings such as items of furniture and ornaments. A lunchtime meal was taken with the residents. The people spoken to were very happy with the meals. They can have a choice and enjoy a well-balanced meal. On the day of the inspection it was breadcrumb mushrooms or orange juice to start, chicken in white sauce with carrots and potatoes or a vegetarian alternative with mandarin oranges in jelly to follow. The meal was served hot and presented well. The two residents who were happy for the Inspector to join them were able to say what was for dinner but had not been asked if they would like the alternative and did not have access to the menu. (Recommendation). The dining room is a beautiful, inviting room but noisy throughout the mealtime and has a constant stream of staff coming and going making it difficult to relax and enjoy the meal properly. (Recommendation). Hethersett Hall DS0000048257.V269701.R01.S.doc Version 5.0 Page 14 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 and 18 Residents and relatives can be confident that their complaints will be listened to and acted upon. Residents are protected from abuse. EVIDENCE: The Home has a complaints procedure that is in the service users guide and advertised on the notice board. On talking to residents they would all feel able to talk to the Manager about a concern and feel it would be acted on. The Home had received an official complaint that was acted upon straight away and was dealt with in a professional manner. The outcome was the family and resident are now pleased with the service provided. This was discussed with the resident who is contented and happy with everything provided at Hethersett Hall. The Commission has not received any complaints directly. Staff, are all trained in the understanding of abuse. The Home will ensure that new staff recruits have this training as part of their induction. The Home does have a whistle blowing policy and all staff, have been checked through the POVA and CRB to ensure the person is suitable to work with vulnerable people. (Three staff files seen). Hethersett Hall DS0000048257.V269701.R01.S.doc Version 5.0 Page 15 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, 25 and 26 Residents live in a safe and well-maintained Home. Residents have safe and comfortable in and outdoor facilities. There are sufficient toilets and washing facilities. The Home is safe with comfortable surroundings. The Home is clean, pleasant and hygienic. EVIDENCE: The Home employs a full time maintenance officer who has clear records of all the maintenance required within the home. The fire records were seen that included fire alarm weekly checks and the servicing of all the fire equipment and smoke detectors. All areas walked appeared well maintained and all fire exits were clearly marked and not obstructed. The Manager talked of the plans for areas to be refurbished and taking place at the time of the inspection was Hethersett Hall DS0000048257.V269701.R01.S.doc Version 5.0 Page 16 the installation of new assisted baths. The large roof is about to be replaced with half planned for this financial year and half for the next. The Grounds are kept neat and tidy with gardening staff employed to look after the large grounds. Plans are in place for the development of a sensory garden attached to the Garden House, which will enable the residents to move outside safely and in stimulating surroundings. The Home have to date had to move residents from one floor to another to have an assisted bath. The installation of a total of four new baths will allow residents in the House to remain on the same floor for a bath and the residents in the Garden House will have two new bath facilities. There are sufficient toilets throughout the building and some rooms have showers. The temperature of the water in three areas that were tested by hand had one area that appeared a little hot but on probing it registered at 44 degrees which is seen as suitable. The records of all water temperature checks were seen in the maintenance officers recording book. All the radiators had thermostatic valves and were covered. The Home appeared warm and each bedroom seen had plenty of natural light. The Home has just completed an extension to the laundry. It is awaiting a hand washing sink and on the day of the inspection was having installed the liquid soap feeds to the washing machines. All the areas were clean and tidy, the floor was covered in a suitable washable surface and dirty laundry was in appropriate bags. Hethersett Hall DS0000048257.V269701.R01.S.doc Version 5.0 Page 17 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, 29 and 30 Resident’s care needs, are met by the numbers and skill mix of the staff. But re-deployment of some of those hours needs to be looked at. The Homes policy and procedure is there but not every element is followed. Staff are well supported and trained to carry out their jobs competently. EVIDENCE: The rota’s were discussed which had created some difficulty in ensuring the correct amount of people were on duty at the times required to meet the needs of residents . Although the number of staff appeared adequate the different times people were employed did not reflect the busiest times of the day. Residents did say they were happy with their care and only one comment card stated more staff may be required in the evenings. On discussing with the Manager and Deputy Manager these complicated rota’s, it was made clear that there were enough staff on duty but not always at the times care needs dictated. The Manager said the review of this rota will take place as the Home increases the resident numbers with a proposed extension. The rota needs to reflect the times care is required and should be looked at as soon as possible. (Recommendation). Three personnel files were looked at. Each one had a check sheet in the front to ensure all paperwork sent for and had been received. It was noted on two Hethersett Hall DS0000048257.V269701.R01.S.doc Version 5.0 Page 18 files that a second reference had not been obtained with one only holding a personal reference. Both staff members have been employed now for a few months and the second reference must be obtained. (Requirement). The Home is working closely with the Training Officer of Barchester Healthcare to establish the training required for staff to deliver the care needed in both areas of the building. Dementia care mapping is to be implemented and staff are using the strengths identified in this ten bedded unit to begin to map individuals. The staff spoken to (two in the Garden House and three in the main House) all stated they are having far more support and training than before and feel the service is improving as their knowledge and skills develop. The most recent training completed was fire awareness, medication and dementia. Past and future planned dates were seen on the staff notice board and also in the Managers diary. Hethersett Hall DS0000048257.V269701.R01.S.doc Version 5.0 Page 19 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, 33, 35 and 38 Residents live in a Home that is managed by a competent person who is fit to be in charge. The Home does carry out quality audits but does not have a format that compiles all the information to share the outcomes with interested parties. Resident’s financial interests are safeguarded. The health, safety and welfare of all people within the Home are promoted and protected. EVIDENCE: This manager has only been in post for seven months but has a lot of experience from managing other Homes. She has just completed her Hethersett Hall DS0000048257.V269701.R01.S.doc Version 5.0 Page 20 Registered Managers Award and is awaiting the arrival of the certificate. She has a good amount of knowledge within dementia care and this is evident both in the conversations held with staff and the systems seen already being introduced to the Home. The Home has a set programme of quality audits that are checked every month, which are directed by the Barchester company. These are fed back to the company and action is taken when areas of shortfall are highlighted, but to date no official document has been produced to show all interested parties the outcome of a completed quality check. (Recommendation) The Home does not handle any of the resident’s money. The resident or family are sent a bill for any expenditure such as the hairdresser or newspapers and the families are asked to provide clothing or toiletries when required. There is a place to store valuables if required for example when someone goes into hospital and they wish the Home to look after a personal item. The Manager has systems in place for all people in the building so they can carry out their tasks safely. Staff are trained and have fully serviced equipment for the moving of residents (Hoists seen and dates of service noted). The Home has liquid soap and paper towels as part of the infection control procedures and staff are aware of cross contamination as explained by the laundry staff member. Records of COSHH safety sheets were seen for all chemicals stored in the building with the master copies in the office and copies placed wherever the chemicals are stored. All accidents and injuries are recorded and serious injuries/incidents and death are to be sent to the Commission from now on. (Regulation 37’s to date had been held on file until the inspection as requested previously). After discussion the forms will now be sent directly to the Inspector. Hethersett Hall DS0000048257.V269701.R01.S.doc Version 5.0 Page 21 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 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X x x 3 3 STAFFING Standard No Score 27 3 28 X 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Hethersett Hall DS0000048257.V269701.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? No 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 Regulation 13.2 Requirement The Registered Manager must ensure all medication is signed for on the MAR sheets to include either a code if not required or the initials of the staff member if administered. The Registered manager must ensure that all staff employed have two references on file as listed in Schedule 4 (6) of records to be kept in the Home. Timescale for action 13/01/06 2 OP29 17.2 13/01/06 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. 2 3 Refer to Standard OP15 OP15 OP27 Good Practice Recommendations It is recommended that residents have the menu available on the table to discuss and enable clear choice. It is recommended that the meal time process is made less busy and quieter allowing meals to be enjoyed in a relaxed environment. It is recommended that the staff rota’s be revised to make clear the times staff are employed and that this at the DS0000048257.V269701.R01.S.doc Version 5.0 Page 23 Hethersett Hall 4 OP33 times the care needs are at their greatest. It is recommended that the collating of all the quality audits and the outcomes that are carried out monthly are available for all interested parties. Hethersett Hall DS0000048257.V269701.R01.S.doc Version 5.0 Page 24 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 Hethersett Hall DS0000048257.V269701.R01.S.doc Version 5.0 Page 25 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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