Inspection on 06/08/08 for Hethersett Hall

This inspection was carried out on 6th August 2008.

CSCI found this care home to be providing an Poor service.

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

Hethersett Hall 06/02/09

Hethersett Hall 09/11/06

Hethersett Hall 12/01/06

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 13/11/2008.

CARE HOMES FOR OLDER PEOPLE Hethersett Hall Hethersett Norwich NR9 3AP Lead Inspector Kim Patience Unannounced Inspection 6th August 2008 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 Hethersett Hall DS0000048257.V369958.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Hethersett Hall DS0000048257.V369958.R01.S.doc Version 5.2 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 www.barchester.com/oulton Barchester Healthcare Homes Ltd Position vacant Care Home 70 Category(ies) of Dementia - over 65 years of age (50), Old age, registration, with number not falling within any other category (20) of places Hethersett Hall DS0000048257.V369958.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th November 2006 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 where some consists of two storeys provides residential accommodation for older people and the Garden House, which provides residential accommodation for older people with dementia. Hethersett Hall’s accommodation consists of 44 single and 2 double bedrooms with ensuite facilities in the Main Hall, and the Garden House accommodation consists of 21 single with en-suite facilities. Barchester Healthcare Ltd owns Hethersett Hall and is situated on the outskirts of the village of Hethersett, approximately two miles from the A11. The range of weekly fees is £750 - £900. Hethersett Hall DS0000048257.V369958.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means the people who use this service experience poor quality outcomes. This inspection consists of information gathered since the last inspection and a site visit, which was held over two days and took approximately 11 hours to complete. During the site visit we looked at records relating to people living and working in the home, records relating to the running of the business and we spoke with residents and staff. The site visit mainly focussed on people with dementia and the area of the home in which they live. Many people were unable to communicate their views verbally; therefore we made observations of people engaged with staff and the surroundings in order to identify signs of wellbeing or ill being. A number of surveys were sent out to residents and staff. However, at the time of writing this report the surveys had not been returned and therefore we are unable to include those comments. What the service does well: What has improved since the last inspection? The home now informs the Commission of all serious incidents affecting the health and welfare of people living in the home. Hethersett Hall DS0000048257.V369958.R01.S.doc Version 5.2 Page 6 Due to the changes in management we were not fully able to assess other improvements made. What they could do better: Since the last inspection there have been changes in management, which have resulted in a lack of proper leadership and management. The home now has a new manager who is experienced and the manager stated that the home will now make rapid improvements to the standard of care. We found that care planning and associated records need some improvement so that the home can demonstrate people’s health and welfare needs are being met. Assessments need to be more person centred, particularly for those people with dementia so that they continue to live a life that is consistent with their previous experiences. Medication administration practice was found to be poor and the home needs to ensure that all staff are trained and their competency is assessed. In addition, there must be systems in place for monitoring medication to identify areas that need to be improved and to ensure good practice all round. The mealtime experience must be improved so that people are able to enjoy the experience of dining, as this should be a positive social experience for people with dementia. In addition, people must be given support to dine in a manner that respects their privacy and dignity. The home must ensure that they provide meaningful occupation and stimulation for people with dementia. In addition to people’s previous life experiences, this must also be based on people’s individual interests and hobbies. The environment in Garden House must be clean and free from offensive odours. Some improvements are required in order to promote independence, privacy and dignity. Room doors must not be locked and people must not be restricted from freely entering their private accommodation. Any health and safety risks such as hazardous products must be risk assessed and action taken eliminate risk. The numbers and deployment of staff must be reviewed to ensure there are adequate numbers of staff available on all shifts. Staff must be provided with full induction training and the necessary training to fulfil their role effectively. New staff must not start working at the home until all pre employment checks have been completed and staff files must be maintained in accordance with the regulations. Hethersett Hall DS0000048257.V369958.R01.S.doc Version 5.2 Page 7 Management systems that promote the continuous improvement of the service must be in put into action to ensure that people are provided with the service they expect to receive. 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. The summary of this inspection report can be made available in other formats on request. Hethersett Hall DS0000048257.V369958.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Hethersett Hall DS0000048257.V369958.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. People who wish to live in this home can be assured that their needs will be met and that they are provided with information that will enable them to make an informed decision about living there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We looked at the policies and procedures in place for people coming to live in the home. We found that the home ensures that pre admission assessments are completed prior to anyone moving in. People are invited to look at the accommodation and services and the home confirms in writing that they are able to meet the person’s needs. Each person is given a brochure so they know what service they can expect to receive and documents are sent out to relatives in order to gather information about people’s life history. Hethersett Hall DS0000048257.V369958.R01.S.doc Version 5.2 Page 10 Care plans are generally completed within a week of people being admitted to the home. However, during that time the pre admission assessment provides adequate information to meet people’s initial care needs until more detailed care plans are completed. Hethersett Hall DS0000048257.V369958.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is poor. People living in the home cannot be assured that their health, care and social needs will be fully assessed and met. In addition, people cannot be assured that they receive medication in a way that safeguards their health and wellbeing. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We looked at care plans in the Garden House: this is a part of the home in which people with more advanced dementia live. We found that each resident had a file containing records relating to their health and care needs. Each file contained an identifying photograph of the resident. The range of assessment and the format of documents is good. However, the quality of the information and how the assessments were being completed was variable; in some cases the files contained more person centred Hethersett Hall DS0000048257.V369958.R01.S.doc Version 5.2 Page 12 information than others and we found that care plans were not being regularly reviewed and up dated to reflect peoples current needs. Senior care staff prepare the care plans when people are admitted to the home, the deputy manager said this is normally done with the involvement of residents and their relatives if appropriate. The care plans looked at did not show evidence of involvement as stated and there did not appear to be anywhere for people to sign in agreement with their care plans. Some people’s care plans showed conflicting information. For instance, for one person there were three care plans relating to mobility that showed different information. Some health assessments and risk assessments were not followed up with a plan of action. For instance, a falls assessment stated the person was at moderate risk yet there was no plan of action to reduce the risk. A waterlow assessment stated the person was at high risk yet no plan of action to minimise the risk. This also links with the nutritional needs assessment, which stated low risk yet the person had lost weight and had poor skin integrity. Care plans written for activities were not necessarily based on people’s previous experiences. Activities records did not show that people were being provided with activity and stimulation. For instance, one record showed that no activity had taken place in the last two months. The home does have daily living profiles, however these were not completed and for one person it appeared that they had only been offered a shower on two occasions so far this year. The home has recently introduced ‘memory lane’ records, but we did not see any in the records we looked at that had been completed at the time of the inspection. We looked at how the home supports people living in Garden House with their medication. We did this by looking at the storage, administration and record keeping. When not in use, medicines are stored in a secure room. The home has a lockable trolley for the transportation of medicines around the home when they need to be administered. There is a separate lockable cabinet for the storage of controlled drugs and a register is used to record all controlled drugs administered. The home also has a fridge for the storage of medicines that require refrigeration. We observed a senior care assistant administering medicines following lunch. What we observed was poor practice, as there were two people involved with the preparing, administering and recording of medicines. For instance, the senior care assistant stood with the trolley and checked the medication charts Hethersett Hall DS0000048257.V369958.R01.S.doc Version 5.2 Page 13 giving instruction to a care assistant who prepared the medicines and took them to residents. The senior then signed the charts to verify the medicine had been taken without seeing it happen. On at least three occasions the person standing with the trolley moved away from it leaving the trolley door open and medicines unattended whilst assisting residents. The medicines are supplied by the local pharmacy who also supply pre printed medication charts. They were all stored in one folder without any separation between each person’s charts. There were no identifying photographs or other relevant information, such as any allergies and special arrangements for administering medicines. When the senior was asked if any medicines were administered covertly, we were told that there was one person who had medicines disguised in their breakfast and that permission to do this had been sought from a relative. When we looked at the records there was no evidence of a multidisciplinary agreement or an assessment of the person’s capacity to consent (in accordance with the Mental Capacity Act 2005). In addition, there was no evidence of consultation with a pharmacist to establish that the medicines would not be affected by mixing with foodstuffs or any care planning to this effect. When we examined the charts we found that there were gaps in some charts where it could not be determined if medicines had been given or not. There were also numerous codes, which were used incorrectly or not defined. For instance, the code ‘N’ denotes ‘PRN’ (as required) medicines ‘not required’ but this had been used on many charts for medicines that were prescribed for regular use. Also code ‘F’ meaning ‘other’ was stated but no further reason indicated. When comparing the charts to the monitored dosage system containers, from which tablets are dispensed, we found that some tablets remained when the chart indicated they had been given. We also noted there were lots of refused medicines that were being disposed of. The deputy manager stated that Barchester and the community pharmacy complete annual reviews of medication. In addition, the deputy said they complete internal audits of medicines. However, we found that there were discrepancies where records did not confirm that medicines were being given to people in line with prescribed instructions. The deputy manager also said that all staff are trained to administer medicines by an external training organisation. However, when we examined the training records this did not appear to be the case for all staff. Some staff files only contained training that had been carried out by senior staff. We did note some assessment of staff competence. Hethersett Hall DS0000048257.V369958.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. People living in the home can be assured that they are provided with good nutritious meals of their choice. However, they cannot necessarily be assured that the mealtime experience will be a positive social experience. In addition, people cannot be assured they will be provided with occupation and stimulation that is consistent with their previous lives. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We looked at care plans and other records relating to people’s interests and hobbies. As already mentioned previously, we saw that the records for some people contained very little relating to how their needs in relation to activity and stimulation are being met. During the site visit there was little happening for people and most were seen sitting in the lounge or sleeping. One resident was observed in a lounge alone and there were periods of time when no staff were around and there was nothing to provide occupation in the room. We observed the resident holding her head in her hands and moaning. Hethersett Hall DS0000048257.V369958.R01.S.doc Version 5.2 Page 15 In general, the environment is equipped to provide activity. For example Garden House has a kitchen that is accessible to residents and they could be encouraged to engage with the activities of daily living. On the day of the visit we did not see people being encouraged to do this. When a resident expressed an interest in clearing up after lunch, the care assistant was heard saying that they have a machine that the dishes go into to be washed. We observed the mealtime experience in Garden House. The tables were nicely set with tablecloths, placemats, cutlery and napkins. The environment was quiet and low stimulation, which is good. It was noted that the dining room had lots of flies in it. One resident commented on the flies and a care assistant said “I can’t see any flies” when they were clearly visible. People were seated at tables at 12:00. The meal was served at 12:30 and by that time some people had fallen asleep and some others appeared confused about why they were there. One resident was saying she was ‘fed up of waiting’. Food was plated up from a hot trolley and each resident was shown a choice of two plated meals, this enables people to make an informed choice about the food they wish to eat. However, there was no choice of drinks to go with their meal. Food was served on green plates all of the same size, however the meals were served in various sized portions which shows individual needs are taken into account here. The food looked appetising and residents appeared to enjoy their meal, people were given time to eat at their own pace. Some people needed assistance to dine and this was not necessarily provided in a discrete and sensitive manner. For instance, one care assistant was standing by the side of a resident and forking the food into her mouth, then moving away to assist another person. Some care assistants were seated at the tables eating a meal with the residents, whilst this is good practice and serves as modelling and prompting people who have loss of recall, it did not work as intended. For instance, one care assistant sat between two residents eating her meal and at intervals assisting one then the other by placing food in their mouths. It was also noted that the dining room was very quiet and lacked social interaction and meaningful stimulation that would enhance the whole experience of dining. Hethersett Hall DS0000048257.V369958.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. People living in the home can be assured that complaints and safeguarding matters will be taken seriously and investigated fully. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We looked at the way in which the home handles complaints and found that there is a complaints procedure that is publicised in the entrance hall and in the homes resident information pack. The manager stated that there have been no complaints since she started 4 weeks ago. However, since the last inspection the commission has been made aware of one complaint that was sent to the home and investigated but the complainant was not satisfied with the outcome. We looked at the complaint investigation and found the regional operations director completed a full investigation and some elements of the complaint were upheld. Some areas of concern raised in the complaint have also been addressed in this report. There has been one safeguarding matter relating to residents finances that is still under investigation. All staff are trained in safeguarding and the subject is included in the annual training plan. Hethersett Hall DS0000048257.V369958.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is adequate. People living in the main part of home are provided with a well-maintained, clean environment. However, the same cannot be said for the people living in the Garden House. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We completed a tour of the premises and viewed the external environment. The home is set in pleasant surroundings and people have access to nice areas outside the home. The gardens are well maintained and there are safe, enclosed areas for people living in Garden House. On entering the home we found that the environment in the main part of the home is nicely decorated and well maintained. People’s individual living Hethersett Hall DS0000048257.V369958.R01.S.doc Version 5.2 Page 18 accommodation is of a good standard and personalised. People spoken with said they liked living in the home and enjoyed the pleasant surroundings. We looked at the environment in Garden House, which is a wing of the home where people with dementia live. The door to this part of the building is secured with a keypad and can only be entered or exited by entering the code number. It was noted that the number was displayed in large print on the wall by the door inside the unit. The home has taken advice from a specialist in designing for dementia and as a result has made some changes to the environment in order to increase the well being of people living in Garden House. For instance, the exit door out of the unit and the surrounding wall has been painted with an outdoor scene to disguise the door and prevent people becoming distressed by trying to get out of the door. When we entered Garden House, offensive odours could be detected. These odours were stronger in some other parts of the unit such as the quiet lounge. In addition, the appearance of the unit in some areas was not clean, particularly in the lounge where the carpet was stained. Some of the chairs in the lounge/dining room also had a noticeably offensive odour when we sat on them. The corridors leading to people’s private accommodation were nicely decorated and by each bedroom door was a picture frame containing pictures and memorabilia relating to the individual who lives there. This helps to aid memory and recall. However, not all room doors had names on them. The corridors were lined with items of interest and things for people to stop and touch. These also serve to stimulate conversation and engagement with the surroundings. There was a lack of clear directional signage and improvements could be made here. People’s rooms were generally clean and tidy. Some were a little sparse but on the whole most were personalised. It was noted that some bedroom doors were locked and when questioned staff said this was to prevent other people entering the rooms and taking things. Staff also said that rooms were locked at the request of relatives but there was no documentary evidence of this. One member of staff said that if ‘someone was locked in their room they could get out easily as operating the handle in the usual way would unlock the door from the inside’. Barchester state they have a policy of not locking doors. One bedroom door had a sensor on it so staff would know when someone is entering the room. We looked at health and safety in relation to the risks for people with dementia. We found that the en suites in some rooms contained products that may be hazardous if misused or ingested. For instance, we found denture cleaning tablets and other toiletries. We also found that whilst the home had lockable cabinets in the en suites, they were not locked, and prescribed creams Hethersett Hall DS0000048257.V369958.R01.S.doc Version 5.2 Page 19 and other products were contained within. In addition, there were no risk assessments in place. In some rooms we saw that people’s dignity was not being promoted, as there were incontinence pads that were visible in people’s rooms. The home employs a range of ancillary staff to support the smooth running of the home and laundry services. Hethersett Hall DS0000048257.V369958.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30. Quality in this outcome area is poor. People living in the home can be assured their needs will be met by a good range and skill mix of staff. However, they cannot be assured that the home has recruitment practices that protect people and that all staff are trained to meet the various needs people have. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We looked at the number of staff working in the home on each shift. At the time of inspection there were 68 residents being accommodated, including 21 people with dementia. The manager said that the home aims to have 13 staff on duty in the morning; 7 staff on duty in the afternoon and 4 on duty at night. The manager also said that the staffing arrangements were being reviewed to ensure that staff are deployed in the most effective way. In addition, it was said that the number of staff on duty in the afternoon was to be increased. We looked at how trained and how skilled the staff team are and found that the home employs a good range and skill mix of staff. A training officer is employed to plan and deliver an annual training programme, which includes mandatory training such as moving and handling, fire safety and adult protection. It was difficult to get a full picture of the training people have Hethersett Hall DS0000048257.V369958.R01.S.doc Version 5.2 Page 21 received up to date, as the home does not yet have a system in place whereby this information can be easily accessed. However, we spoke with the training officer who was able to show us the training provided. Staff are offered a good range of training in various forms, such as e-learning and that delivered by the in-house trainer. When we looked at staff files it was apparent that some people had not had some of the mandatory training and had not completed a full induction. In addition, not all staff working with people with dementia and administering medicines had received formal training. When we looked at the homes recruitment practice we saw that the files relating to new staff were not being kept in accordance with the regulations. For instance, there were no identifying photographs in some files. We also found that in all cases looked at, staff had started working in the home before all the pre employment checks had been completed. In at least two cases, staff had started work without a POVA check or CRB and poor or inadequate references. Hethersett Hall DS0000048257.V369958.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome area is adequate. People living in the home can be assured it will now be well managed. However, quality assurance audits need to be improved in order to demonstrate this. In addition, staff need to be supervised to identify further training needs and to ensure they are fulfilling their role effectively. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has had four changes in management over the last year and the recently registered manager has now left. An experienced registered manager from another Barchester home has taken the post at Hethersett Hall and has already identified many areas for improvement. Hethersett Hall DS0000048257.V369958.R01.S.doc Version 5.2 Page 23 The home does have quality assurance systems in place that includes consultation with stakeholders by way of surveys and meetings. The results of the annual quality assurance assessment is published and made available to people who may have an interest in the service. There are also regular monthly audits of specific aspects of the service. However, the quality and effectiveness of the audits is questionable considering some of the findings in this report. The home does not now have any involvement with resident’s finances. The new manager is aware that staff supervision has not been taking place and is introducing a programme of supervision for all staff. However, at the time of the inspection not all staff were being provided with supervision on a one to one basis. We looked at health and safety requirements and found that the home is maintaining good fire safety procedures and has the necessary health and safety risk assessments in place. All equipment is serviced regularly under contract with external service providers. We have identified some aspects of health and safety that still require improvement. Hethersett Hall DS0000048257.V369958.R01.S.doc Version 5.2 Page 24 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 X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 2 Hethersett Hall DS0000048257.V369958.R01.S.doc Version 5.2 Page 25 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 15.1 Requirement Written care plans should be prepared for all aspects of care, health and wellbeing. Where possible the resident and/or their representative should sign to denote their agreement. So that people’s needs can be met with a plan of care that is agreed by all parties involved. Written care plans and associated assessments must be reviewed and updated to accurately reflect people’s current health, care and welfare needs. So that their current needs can be met. Risks to people’s safety must be identified and eliminated where possible. So that people’s health and welfare is safeguarded. Medication management must health and wellbeing of residents. So that they are safeguarded from harm. This is repeated for the third consecutive time. People who need assistance to dine must be supported in a discrete and sensitive manner. DS0000048257.V369958.R01.S.doc Timescale for action 30/09/08 2. OP7 15.2 30/09/08 3. OP8 13.4c 30/09/08 4. OP9 13.2 30/09/08 5. OP15 16.2i 30/09/08 Hethersett Hall Version 5.2 Page 26 6. OP26 16.2k 7. OP30 18.1c 8. OP29 19.1 9. OP36 18.2 So that their privacy, dignity and wellbeing is promoted. The home must be clean, hygienic and free from offensive odours. So that people’s health and wellbeing is promoted. Staff must be provided with training so that they can meet the various needs of people living in the home effectively. Recruitment practice must promote the safety and welfare of people living in the home. So they are protected from harm. All staff must be provided with appropriate supervision. So that people’s health and wellbeing is promoted. 30/09/08 30/09/08 30/09/08 30/09/08 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 OP27 OP19 OP33 Good Practice Recommendations The home should review the number and deployment of staff on each shift. The home should continue to seek advise about designing for dementia in order to promote independence and wellbeing. Quality assurance audits should be effective so that the home self regulates and continuously improves the service. Hethersett Hall DS0000048257.V369958.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V369958.R01.S.doc Version 5.2 Page 28 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!