Inspection on 16/06/05 for Hethersett Hall

This inspection was carried out on 16th June 2005.

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 12/01/06

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 Norfolk NR9 3AP Lead Inspector Ruth Hannent Unannounced 16 June 2005 06:15 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. Hethersett Hall I55 s48257 hethersetthall v233395 160605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Hethersett Hall Address Hethersett Norwich NR9 3AP 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) 01603 810478 01603 810860 Barchester Healthcare Homes Limited Mrs Isobel Randle Care Home 54 Category(ies) of Dementia (10), registration, with number Old age, not falling within any other category of places (44) Hethersett Hall I55 s48257 hethersetthall v233395 160605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: A full review and assessment of the accomodation will take place within 3 months of Barchester Healthcare taking over ownership of the home with a view to achieving the number of registered places that reflects the actual provision and capacity of the home. Date of last inspection 18th November 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 44 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 Hall’s 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 I55 s48257 hethersetthall v233395 160605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out as an early morning unannounced inspection, taking place with the night staff of Hethersett Hall over a one hour period between 6.15am and 7.15am. The purpose of the inspection was to check on what were the routines at the time of the inspection and to consider if these practices promote the welfare and safety of the residents accommodated. Not all Standards have been looked at and requirements or recommendations made from the previous inspection will be examined at the next inspection. Two Senior night staff and the Cook assisted the Inspector. One resident in the Hall and six in the Garden House all spoke to the Inspector. Three care plans were seen Part of the Hall and all of the Garden House communal areas were looked at along with three bedrooms. What the service does well: What has improved since the last inspection? What they could do better: Any part of the service the Home could do better will be included within the next inspection. Hethersett Hall I55 s48257 hethersetthall v233395 160605 Stage 4.doc Version 1.30 Page 6 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 I55 s48257 hethersetthall v233395 160605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Hethersett Hall I55 s48257 hethersetthall v233395 160605 Stage 4.doc Version 1.30 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 standard(s) These standards not inspected on this occasion EVIDENCE: Hethersett Hall I55 s48257 hethersetthall v233395 160605 Stage 4.doc Version 1.30 Page 9 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 and 9 The Home has very clear and comprehensive plans of care to enable staff to assist with the appropriate care required. The night staff team follow the correct, safe procedure for administering medication ensuring the Homes policy safe guards the residents . EVIDENCE: In the main house 2 care plans were seen and each one gave a clear picture of need. The senior night staff member showed a list of people who need help to get up from 6am onwards. The list gave 6 named residents for each morning. One lady was already up and dressed and was able to talk about how she is awake and likes to up and dressed early. This lady was very happy with the care and had only been at Hethersett Hall for a few months but felt she was settling well. In the garden house 6 residents were up and dressed with one in her dressing gown waiting for a bath. They all appeared happy and smiling. The senior night carer explained that some residents start coming from their rooms from 5.30 onwards and are usually assisted from whenever they are awake after that time. Hethersett Hall I55 s48257 hethersetthall v233395 160605 Stage 4.doc Version 1.30 Page 10 One comprehensive care plan was seen but times for getting up or going to bed depended on the individual on the day so recording times is inappropriate. The senior night staff team do not issue medication from the blister pack system but will administer homely remedies such as paracetamol. The senior night staff member showed the storage of the tablets in a locked cabinet, the procedure of always two members of staff to check labels, administer and oversee the signature on to the MAR chart. The information is then written in the daily recoding notes so the next shift are aware the person has received the paracetamol. The two senior night staff members both had covered the Safe Handling of Medicines course in January and also attended the Boots pharmacy training. Hethersett Hall I55 s48257 hethersetthall v233395 160605 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 Residents appear happy and do have the majority of their expectations met but some fine-tuning would help match the lifestyles preferred. Meals discussed and the menus seen do offer a well balanced and nutritional diet offered in the room of the resident’s choice. EVIDENCE: The one lady who was up and dressed had moved to Hethersett Hall to be near her family. She said she was very pleased with her room and “everyone is very kind my dear” was one of the comments stated. She goes to bed at nine but was always up until midnight when she lived at home. (I don’t’ want to bother someone bringing my sleeping tablet after the day staff have finished so I go to bed early). (Recommendation). The Cook arrived early and was able to talk about the breakfast offered to the residents. Approximately six people have their meal on a tray in their room with the rest sitting in the well laid out dining room. They are offered cereals, toast and marmalade, prunes, grapefruit and fruit juice. (Porridge in the colder weather) and on Saturdays bacon and eggs if they wish. The menu for the day was already displayed in the dining room and over in the garden house a menu card is placed on the table. (They are about to have a display wall mounted menu card for all to see). Hethersett Hall I55 s48257 hethersetthall v233395 160605 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) These standards not inspected on this occasion EVIDENCE: Hethersett Hall I55 s48257 hethersetthall v233395 160605 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 Residents live in a well-maintained and safe environment to ensure comfort and safety. EVIDENCE: The Home is maintained and decorated in a keeping with the grand Hall that it is. The entrance hall, lounge and dining room are beautifully furnished with nice curtains and flooring. There is a full time maintenance officer who can be called out to attend a building issue when required. The gardens are kept neat and tidy with a nice enclosed garden area attached to the garden house with a new brick path for people to walk along and take a seat to rest as they go. All the rooms seen have fire doors, with corridors having fire door release catches in the event of the fire alarm ringing. It was noted that the extinguishers were serviced in May 2005. The two senior staff spoken to had clear instructions on the procedure in the event of the fire alarm being triggered. The one senior gave a clear step by step procedure from when the bell sounds to when the brigade arrive. Hethersett Hall I55 s48257 hethersetthall v233395 160605 Stage 4.doc Version 1.30 Page 14 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 and 30 Residents do have their needs met by a number of staff who are experienced and trained to offer a good service. EVIDENCE: On arrival at Hethersett Hall four night senior staff were on duty. Throughout the night three staff were in the main hall with 34 residents with one staff member in the garden room with 10 residents. At 6 am one staff member moves from the hall to the garden house to assist with residents to rise. It appeared calm and unhurried with people being assisted in a caring manner. Rotas were seen in both areas in the diaries kept in the office. The day staff shift started between 7am and 8am with the night team staying until 8am. This gave time for a handover and still ensured enough staff were available to help people up. In total the morning shift had 10 members of care staff between the two buildings. The night staff all cover the 10 hour shift. They are experienced staff with one staff member in post for 12 years and another for 2 years. (Another had recently moved to the home from another Barchester Healthcare Home). On the wall in the office was information on the next session planned for medication training with listed names and signatures of staff wish to cover the course. Both senior staff members have covered the medication training in the past. Barchester Healthcare find an outside trainer as well as using Boots pharmacist to train their staff. One senior mentioned she was always updating her knowledge with training which “Barchester encourage” and holds the NVQ3 in care. Hethersett Hall I55 s48257 hethersetthall v233395 160605 Stage 4.doc Version 1.30 Page 15 When asking the senior night staff the back up support that may be required in an emergency the Inspector was shown a list of 4 names clearly available for all to see on the main office notice board. The one incident for call out remembered by a staff member was the need for the maintenance man in when a building issue occurred. Hethersett Hall I55 s48257 hethersetthall v233395 160605 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) These standards were not inspected on this occasion. EVIDENCE: Hethersett Hall I55 s48257 hethersetthall v233395 160605 Stage 4.doc Version 1.30 Page 17 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 x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x x STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x x x x x x x x Hethersett Hall I55 s48257 hethersetthall v233395 160605 Stage 4.doc Version 1.30 Page 18 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 Regulation Requirement Timescale for action 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. Refer to Standard 12 Good Practice Recommendations It is recommended that the care plans reflect fully the lifestyles of the individuals by empowering the residents to build their own care plans to match their expectations.. 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