CARE HOMES FOR OLDER PEOPLE
Hethersett Hall Hethersett Norwich NR9 3AP Lead Inspector
Maggie Prettyman Unannounced Inspection 6th February 2009 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.V374114.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.V374114.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 Barchester Healthcare Homes Ltd 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.V374114.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: N/A Date of last inspection 6th August 2008 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 which consists of two storeys, provides residential accommodation for older people. 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 en-suite facilities in the Main Hall, and the Garden House accommodation consists of 21 single with en-suite facilities. The Home is owned by Barchester Healthcare Ltd. 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.V374114.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 2 star. This means the people who use this service experience good quality outcomes. Care services are judged against outcome groups, which assess how well a provider delivers outcomes for people using the service. The key inspection of this service has been carried out by using information from previous inspections, information from the provider, some residents and their relatives as well as others who work in or visit the home. This has included a recent unannounced visit to the home. This report gives a brief overview of the service and current judgements for each outcome group. This inspection took place over the course of two days and included discussion with residents and their visitors, inspection of files and written records, a tour of the premises and observation of staff conduct and interaction with people who live at the home. Prior to the inspection a detailed Annual Quality Assurance Assessment was undertaken by the home and submitted to the Commission. What the service does well:
Hethersett Hall is a good Home. It is spotlessly clean, attractive, well maintained. It is a homely place that is set in an attractive countryside location. The Home is run by an experienced and professional manager who works hard with her team to make sure that people enjoy a good service from the Home. People are given good information about the Home when they are thinking about going to live there, have a detailed assessment of their needs made to check that it is suitable for them, and have a contract that sets out their rights of occupancy. One relative said” We could not be happier, they have really helped mum to move here and settle in” While living at the Home people have their health care needs met and are treated by the staff with dignity and respect. People’s autonomy, privacy and individuality are respected. One resident said “ They always treat me kindly, and are polite and respect my wishes.” The food is good at the home and people have a choice of pleasant environments in which to dine.
Hethersett Hall DS0000048257.V374114.R01.S.doc Version 5.2 Page 6 People’s comments and complaints are listened to and action is taken about the things people want changed. Peoples personal possessions are treated with respect and their clothes are well cared for. Staff are carefully vetted before they start working and receive good mandatory training and are supervised. What has improved since the last inspection? What they could do better:
Bearing in mind the size of task that faced the new manager when she arrived, remarkable progress has been made and the Home is well on its way to re establishing its former high standards of service delivery. Some areas of further improvement were identified during the inspection. Residents in the Garden Wing will benefit from better specialist ”Memory Lane” care planning that addresses their specific dementia care needs.
Hethersett Hall DS0000048257.V374114.R01.S.doc Version 5.2 Page 7 Risk assessments for residents need to include how risks identified can be reduced so that staff always understand how best to address risks for each person. Staff should continue to be encouraged to achieve their NVQ 2 in care to expand on their knowledge gained from experience and mandatory training. All written records should be maintained in peoples care plans only and not in a handover book, as this could infringe people’s privacy and prevent effective care plan review. The fire evacuation procedure at the Home needs to be fully completed so that an evacuation would take place smoothly in an emergency. The storage of personal toiletries should be in such a way that peoples own products are labelled as such and stored safely if needs be. Routine Health and safety record checks should be kept up to date so that the homes manager can know that systems are working effectively. 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.V374114.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.V374114.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): Standards 1, 2, 3 and 6. Quality in this outcome area is good. We have made this judgement using a range of evidence, including a visit to the Home. People who use the service and their families are given good information about the Home and have their needs assessed before they come to live there. This means that people can make an informed decision about the home they choose. The Home does not provide intermediate care. EVIDENCE: The Home has a detailed and professional brochure about the service that it offers as well as a comprehensive statement of purpose. There is also a helpful and informative website which is accessible and easy to use. Relatives of someone who came to live at the Home recently were interviewed and said
Hethersett Hall DS0000048257.V374114.R01.S.doc Version 5.2 Page 10 that the information they had been given matched the service that their relative had been given. Administrative files for some people who live at the Home were examined and found to contain detailed information and a signed contract. Care files for people living at the Home were examined and found to contain detailed needs assessments undertaken before people came to live there. During the inspection a member of senior staff was seen going out to assess a prospective resident in their own home. Hethersett Hall DS0000048257.V374114.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): Standards 7, 8, 9 and 10 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the Home. People who live at the Home have their personal and healthcare needs set out in a care plan to ensure that their needs are met. A safe medication system is in place so that people get their medicine as prescribed. Residents are treated with respect and dignity so that their rights in these areas are protected. EVIDENCE: We looked at Care Plans for people living in the main hall and in the Garden Wing. All care plans were found to be detailed and to contain accurate information about peoples care needs. All care plans were found to be signed by the resident where possible. One person said “They came to talk to me about my care plan. I signed it to say I agree with how it says I want to be looked after”
Hethersett Hall DS0000048257.V374114.R01.S.doc Version 5.2 Page 12 All care plans seen were found to be up to date and had been regularly reviewed since the new manager started working at the Home. There were some shortfalls for the care plans seen in the Garden wing. “Memory Lane” dementia specific care planning was not always completed, and risk assessments, although updated, did not tell people how the risk identified could be addressed or reduced. This means that people living in the Garden Wing may not always have their dementia needs fully addressed and risks may not always be reduced. Care plans inspected had good Health Care records in place. Evidence of nutritional and pressure are risk assessment and action was seen in all files inspected. Healthcare records detailed weight screening and appointments and access to Health Care Professionals. Instructions and advice from Health care professionals was recorded and staff were aware of individual healthcare support needs. Items of equipment supporting people’s healthcare needs were well maintained and clean. The medication system at the Home was carefully checked as this had been of concern at the last inspection. The new manager has implemented a range of reviews, audits and procedures that have met the requirements made in the previous report. A medication round was observed. Staff wore a “do not disturb” tabard. Individual medicines were taken from the trolley and it was left securely locked when unattended. Each resident was observed taking his or her medicine before the staff member moved on. Medicines were only recorded as being taken after this had been observed. Drug charts were checked and found to be clearly and accurately recorded. Staff records demonstrated that medication training has been updated. During the inspection all staff at the Home were observed treating residents with dignity and respect. Residents were seen being addressed by their name of choice. Personal care was delivered in private and those residents needing support at mealtimes were helped in a caring and kindly way. People at the Home were seen to receive their post unopened. There is a secluded area where a public telephone is available and many people have their own telephone in their rooms. The laundry was checked, and people’s clothes were seen to be properly labelled and carefully sorted. One resident said, “My clothes are always well washed and ironed, and things don’t get lost here.” Hethersett Hall DS0000048257.V374114.R01.S.doc Version 5.2 Page 13 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): Standards 12, 13, 14 and 15 People who use the Service experience good quality outcomes ion this area. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: Residents were seen living according to their chosen daily routine. A newspaper discussion group was in progress during the inspection in the main lounge. A resident was seen to participate in washing up after lunch in the Garden wing. The nominated activity workers at the Home are currently off sick, but a reduced programme of activities was found to be in place. People living at the home confirmed that they are enabled to maintain their personal relationships. The Home could improve its recording of personal interests and lifestyle choices, in particular in the Garden Wing where “Memory Lane” recording was found to be incomplete. People living at the Home confirmed that their visitors are welcomed and that there are no restrictions made. People’s family members said that staff are always helpful, and that they are offered refreshments when they visit. The
Hethersett Hall DS0000048257.V374114.R01.S.doc Version 5.2 Page 14 Home has a pleasant private dining area in the Library where people can have their family or friends to lunch. People living at the Home were seen to exercise choice and control in their lives. People’s rooms were full of personal possessions and were individualised. People handle their own finances and have the option to have a private telephone line in their room. A resident confirmed that she had seen her care plan and agreed to its contents. Records showed that regular residents meetings are held to consult people about how they wish the Home to be run. The Home has a main dining area, which is comfortably and attractively furnished. People choose on a daily basis whether to eat in the dining room or their own rooms. The Garden wing also has dining areas. People were also seen choosing to eat in their own rooms. People were seen to be offered a choice of meal. In the Garden Wing a care worker presented the choice as sample meals laid out on plates, fresh portions were then served to people according to their choice. People commented that they like the food at the Home and that they are given alternatives if they do not like what is on the menu. A tour of the kitchen demonstrated that it is spotlessly clean and staffed by conscientious and professional catering team. Evidence of residents being involved in menu planning was seen in the form of a recently conducted survey. Hethersett Hall DS0000048257.V374114.R01.S.doc Version 5.2 Page 15 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): Standards 16 and 18 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are able to express their concerns and have access to a robust, effective complaints procedure and are protected from abuse. EVIDENCE: Residents and their families spoken to confirmed that they know who to complain to and how to make a complaint. The Home has demonstrated that it takes complaints seriously and initiates appropriate action when a complaint is made. Staff training records demonstrated that people who work in the Home are trained in safeguarding, and that this training is annually updated. Hethersett Hall DS0000048257.V374114.R01.S.doc Version 5.2 Page 16 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): Standards 19 and 26 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service The physical design and layout of the Home enables people who use the service to live in a safe, well-maintained and comfortable environment, which encourages independence. EVIDENCE: A tour of the premises was undertaken and the location and layout of the Home demonstrated that it meets the needs and expectations of the residents who live there. Communal areas are accessible and the Home is attractively furnished and well maintained. There is a comfortable and homely atmosphere throughout the Home. The grounds are well kept and a secure garden makes a pleasant outdoor area for the residents of the Garden wing.
Hethersett Hall DS0000048257.V374114.R01.S.doc Version 5.2 Page 17 During the inspection it was noted that a full fire evacuation procedure and drills have not been fully developed. The manager confirmed that work on this is in progress and will be completed in the near future. The tour of the premises demonstrated that the Home is clean, hygienic and pleasant throughout. Some unmarked personal toiletries and soaps were found in communal bathing areas, but were removed during the inspection. Staff were seen wearing suitable protective clothing and observing good hygiene practice. A visit to the laundry demonstrated that clothes and linens are carefully handled and washed correctly. Clothing examined in the laundry had personal name marking. Residents confirmed that their clothes are returned to them promptly and in good condition. Hethersett Hall DS0000048257.V374114.R01.S.doc Version 5.2 Page 18 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): Standards 27, 28, 29 and 30 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff in the Home are trained and in sufficient numbers to support the people who live there. EVIDENCE: During the inspection a good level of staffing was observed. People were seen working hard, but in an unhurried and calm manner. It was also noted that the domestic and catering teams were working diligently to provide a consistent and professional service. The Homes work rota demonstrated that staff absence is covered by replacement staff. The Home does not have a high level of staff that have completed NVQ level 2. This is in part due to a recent turnover of staff. The manager said that the Home is actively addressing this shortfall by placing new staff on NVQ training. A selection of staff personal files was examined and was found to meet the vetting requirements of the care standards.
Hethersett Hall DS0000048257.V374114.R01.S.doc Version 5.2 Page 19 Staff training records demonstrated that they receive induction when they start work at the home. There were also records that demonstrated that mandatory training is undertaken and updated for all staff. Specialist training is also provided to ensure that staff can meet the needs of people living in the Garden Wing. Hethersett Hall DS0000048257.V374114.R01.S.doc Version 5.2 Page 20 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): Standards 31, 33, 35 37 and 38 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The management and administration of the Home is based on openness and respect. The Home is developing effective quality assurance systems under the direction of a qualified and competent manager. EVIDENCE: A trained, skilled, experienced and competent manager has taken over running the Home following some serious problems at the Home. She demonstrated a high level of competence and professionalism during the inspection, and has a good record of effective management in her previous post. She is in the
Hethersett Hall DS0000048257.V374114.R01.S.doc Version 5.2 Page 21 process of completing her registration as manager of the Home with the Commission. The Home is part of a group which undertakes external Quality audit of all its Homes. The results of the most recent survey have yet to be published. Prospective and current residents would benefit from being given copies of these surveys. The Home holds regular resident meetings and a relatives committee is in the process of being established. Action, including the provision of suggestion boxes, is taken as a result of comments and suggestions made in these forums. The Home does not handle money on behalf of any residents. Inspection of the Homes r4ecords demonstrated that the “Handover book” contained information that should have been recorded privately and individually in peoples care plans. The Home should address this as this practice not only breaches data protection principles, but also could compromise peoples care planning and review. Examination of staff training records demonstrated that staff are trained in health and safety in relation to their roles. During the inspection, some issues relating to Health and Safety such as toiletries left out in communal bathrooms in the Garden wing, an incomplete fire evacuation plan and recent lapse in routine safety checks were identified. Whilst these were addressed during the inspection, the Home needs to ensure that similar shortfalls do not occur in the future. Hethersett Hall DS0000048257.V374114.R01.S.doc Version 5.2 Page 22 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 3 3 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 2 2 Hethersett Hall DS0000048257.V374114.R01.S.doc Version 5.2 Page 23 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. Standard 1. OP7 Regulation 15.1 Requirement Specialist Memory Lane care planning must be completed for all people living in the Garden Wing so that their dementia care needs can be fully addressed. The procedure for evacuation of the premises must be evaluated to ensure that a safe evacuation of the Home would be undertaken in the event of an emergency. All information relating to individual residents must be kept in their care plan and not in other records so that people know what is written about them and so that their care plan can be accurately reviewed. The Lapses in Health and Safety monitoring and recording identified during the inspection must be monitored to ensure that these systems become part of regular custom and practice at the Home Timescale for action 30/08/09 2. OP19 23.4c 30/04/09 3. OP37 15 30/04/09 4. OP38 12 and 23 30/04/09 Hethersett Hall DS0000048257.V374114.R01.S.doc Version 5.2 Page 24 5. OP7 13.4c Risk assessments must always include what action should be taken to reduce the risk identified so people’s health and welfare are safeguarded. 30/04/09 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 OP33 Good Practice Recommendations The outcomes of Quality Assurance surveys should be made available to current and prospective residents and their families so that people know what people living in the home think of its service. The Home should continue to work toward enabling its staff to have NVQ 2 in Care The Home must continue to check that unmarked toiletries and soaps are not left in communal bathing areas. Personal lifestyle choice and wishes should be recorded in peoples care plans so that their wishes can be met. This is of particular importance for residents in the Garden Wing 2. 3. .4. OP28 OP26 OP12 Hethersett Hall DS0000048257.V374114.R01.S.doc Version 5.2 Page 25 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
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