Inspection on 09/11/06 for Hethersett Hall

This inspection was carried out on 9th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Hethersett Hall 06/02/09

Hethersett Hall 06/08/08

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Hethersett Hall Hethersett Norwich NR9 3AP Lead Inspector Maggie Prettyman Unannounced Inspection 9th November 2006 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.V319618.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.V319618.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 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.V319618.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th January 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 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. The range of weekly fees is £450 - £600 Hethersett Hall DS0000048257.V319618.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. 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 other 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. What the service does well: What has improved since the last inspection? This home is continuing to improve its facilities and working practice. A comprehensive programme of building work is in progress. Redecoration and upkeep of the premises and décor is ongoing and to a high standard. Outdoor access and interior facilities for service users in the Garden House have been significantly improved. Individual plans of care are being updated into a new, clearer format. The manager has achieved her Registered Managers award and a new programme of E Learning and centralised training records has been implemented. Hethersett Hall DS0000048257.V319618.R01.S.doc Version 5.2 Page 6 What they could do better: This home is achieving good standards in many areas. However some areas of shortfall and improvement were identified during the inspection, which are detailed at the end of this report. Requirements: • • • Repeated Requirement Medication records are still not being completed in full as required. Notifiable incidents are must be reported in full to the Commission Service users access to the call system in the garden house must be investigated and individually risk assessed Recommendations; • • • • • • • • The service user guide could be more accessible to service users with dementia care needs The new care plans should be completed as soon as possible, with duplicate handover notes ceased when in place Activities in the Garden House should be displayed in a way which is accessible to service users with dementia care needs The daily menu in the Garden House should be accessible to service users with dementia care needs The home should record and audit comments, compliments and suggestions made with action taken The recruitment process could be strengthened in line with “Safe and Sound” guidelines The quality assurance system should be developed in order that the home becomes fully self auditing and monitoring A more detailed audit of accidents and occurrences could help identify and prevent potential risk situations. 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.V319618.R01.S.doc Version 5.2 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.V319618.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 5 Quality in this outcome area is Good. Prospective service users have the information they need to make an informed choice about where to live. No service user moves into the home without having their needs properly assessed. Prospective users and their representatives have the opportunity to visit the home before being admitted. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A detailed service user guide and statement of purpose are in place. These could be improved to make them more accessible to service users with dementia care needs. A website with virtual tour is also available. The manager is considering making this information available in DVD format. It is Hethersett Hall DS0000048257.V319618.R01.S.doc Version 5.2 Page 9 recommended that the home considers making pre admission information more accessible to service users with dementia care needs. Evidence in service user files and discussion with staff demonstrated that a thorough needs assessment is undertaken prior to a service user being admitted to the home. Discussions with service users and their relatives as well as with staff demonstrated that people are encouraged to visit the home as many times as they wish prior to admission to assess the homes suitability for their needs. Staff from the home also visit service users in their own homes as part of the admissions process. Hethersett Hall DS0000048257.V319618.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. Service users health and personal social care needs are set out in an individual plan of care. Service users health care needs are fully met. Where possible service users are responsible for their own medication. The homes medication procedures protect service users. Service users feel that they are treated with respect and their right to privacy is upheld. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Detailed care plans are in place for all service users. The organisation has recognised that these plans can be difficult to access and have some elements that could be added. This means that a handover book is used that duplicates information recorded. A new improved format has been devised and is in the Hethersett Hall DS0000048257.V319618.R01.S.doc Version 5.2 Page 11 process of being implemented. It is recommended that the new care plans are implemented as soon as possible, and that duplicate handover notes are ceased once these are in place. Pre inspection information from a healthcare professional and service users, as well as inspection of records and discussions with service users and their representatives on the day of inspection, demonstrate that service users healthcare needs are met by the home. A monitored dosage system of medication is in place for those service users that do not handle their own medication. Inspection of records demonstrated that some omissions in signing sheets continue to occur. It is required that the home audits all medication administration records to ensure full recording of drugs dispensed or refused. Pre inspection information as well as observations and discussions on the day demonstrate that service users are treated with the utmost respect and dignity. Private telephone and Internet connection is available for service users in their own rooms. Letters are given unopened to service users. Clothes are carefully looked after and labelled. Service users are addressed by their name of choice. Rooms are recognised as private and personal space and are individually named if the service user wishes. Hethersett Hall DS0000048257.V319618.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. The lifestyle in the home includes a good range of social activities. Community contact is supported and maintained The home is exemplary in offering its service users choice and control. Wholesome and appealing food is served in pleasant surroundings This judgement has been made using available evidence including a visit to this service. EVIDENCE: A comprehensive range of activities is in place in the home. Service users were observed participating in stimulating and interesting activities. A list of activities is posted weekly in the main house. Service users in the Garden House may benefit from having activities promoted in ways that supports people with dementia care needs. It is recommended that activities in the Garden House be displayed in a way that supports service users with dementia care needs. Service users and their relatives described the home as welcoming and supportive of visitors. A variety of community groups and schools come to the Hethersett Hall DS0000048257.V319618.R01.S.doc Version 5.2 Page 13 home to provide entertainment. Religious observance is available regularly in the home or at the local church. The home is exemplary in its work enabling service users to maintain choice and control in their lives. Several people manage their own financial affairs and medication. Rooms are personalised and recognised as personal and private space. Regular residents meetings take place with action taken in response to comments and suggestions. Service users and their relatives are fully involved in reviews of their care plans. Service users described having freedom of choice and expression. A confident and experienc3ed chef heads a hard working team of kitchen staff. Service users described meals as being of good quality, with choice and variety of menu. The kitchen is shortly to be extended to improve facilities as well as improving the dining room. Feedback from pre inspection questionnaires demonstrated that it might be helpful to offer a more flexible time for the evening meal. Menus are displayed prominently at the door of the main dining room. It is recommended that the menu be made more accessible to service users with dementia care needs. The new care plans include the MUST nutritional assessment tool. Hethersett Hall DS0000048257.V319618.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 Quality in this outcome area is good. Service users comments complaints and suggestions are responded to by the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Pre inspection questionnaires and discussions with service users and their relatives demonstrate that the home responds well to comments and suggestions made. The home does not currently record and audit these responses. It is recommended that the home records and audits comments, compliments and suggestions made and action taken, to monitor service user satisfaction. No formal complaints have been recorded by the Home since the last inspection. During the inspection a complaint that had not notified to the Commission was identified. This complaint had been taken seriously and appropriately and satisfactorily dealt with. It is required that the home notifies the Commission of all serious complaints, irrespective of their source, as required by the Care Home Regulations. Hethersett Hall DS0000048257.V319618.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 22, and 26 Quality in this outcome area is good. Service users live in a safe, well-maintained environment. Service users have access to excellent safe indoor and outdoor communal facilities. The call system in the Garden House must be available to service users. The home is consistently clean, pleasant and hygienic. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the premises demonstrated that the home is well maintained and safe. All areas are accessible and suitable for their purpose. A good programme of regular maintenance is in place. The grounds are accessible and extremely attractive. Improvements to the Garden House have improved outdoor access for service users living there. Considerable building work is in Hethersett Hall DS0000048257.V319618.R01.S.doc Version 5.2 Page 16 progress to expand and develop the home. Service users are being kept up to date with developments at information meetings. During the inspection the home recognised that better directional signs and a doorbell were needed for the temporary front door access, and immediately rectified the problem. Inspection of communal areas demonstrated an excellent standard of décor and choice of communal facilities in the home. The dining room in the main house is attractive and welcoming. The communal area in the Garden House is homely and comfortable. Service users in the main house have individual call alarms, which are on their person at all times. Inspection of the Garden House showed that not all service users have access to the call system at night. It is required that service users access to the call system in the Garden House is individually risk assessed and provided as appropriate. A tour of the building demonstrated the home to be spotlessly clean, pleasant and hygienic, with good systems of infection control. Ancillary staff were observed to be hard working and attending to detail. Laundry facilities are excellent, and individual service users clothes are carefully looked after. Hethersett Hall DS0000048257.V319618.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. The home is continuing to work towards NVQ qualification for its staff. The homes recruitment process could be improved in line with “Safe and Sound” recommendations. A co-ordinated and recorded system of internal training is in place. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is yet to achieve 50 NVQ qualification of its staff, but is continuing to work towards this. The Homes’ manager has recently achieved her Registered Managers Award. Examination of staff records demonstrated that there are still some shortfalls in the recruitment process in the home. Gaps in employment are not explored, confirmation of original documentation is not kept, an interview checklist is not used and photographs of staff were not present in files. The home was in the process of a staff file audit during the inspection. A copy of “Safe and Sound” was provided by the inspector. It is recommended that the home apply a more vigorous approach to its recruitment and vetting process. The home occasionally uses an agency for relief staff. The agency used provides written confirmation of CRB clearance, training and experience of workers before they are supplied. Hethersett Hall DS0000048257.V319618.R01.S.doc Version 5.2 Page 18 Examination of training records and discussion with the training co-ordinator demonstrated that a thorough, well-managed staff training and development programme is in place. The organisation has recently instituted an on line “E Learning” training package. Training records are held by the home. The facility to register training centrally within the organisation has just been introduced. Hethersett Hall DS0000048257.V319618.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. The home is run by a competent and committed manager. The home is run in the best interests of service users. Service users financial interests are safeguarded. Service users and staff are protected by safe working practices. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the inspection the manager demonstrated a committed and professional approach to her work. She has recently completed her Registered Managers’ award. Hethersett Hall DS0000048257.V319618.R01.S.doc Version 5.2 Page 20 A variety of internal and external quality assurance process and audits are in place. However the home does not have a formal annual development plan formed from these audits, and the quality assurance surveys are not compiled into a report to be shared with current and prospective service users. It is recommended that the quality audit system be developed according to the Care Standards in order that the home becomes fully self-auditing. Service users or their relatives manage individual financial affairs. No money is held on behalf of service users. A tour of the premises and inspection of detailed maintenance records demonstrated that the health safety and welfare of staff and service users is protected. Hazardous substances are safely stored; equipment is regularly maintained and serviced. A potential fire hazard was identified during the inspection, which was immediately resolved by the home. Accidents and occurrences are recorded and reported and audited by the organisation. It is recommended that a more detailed audit of accidents and occurrences be undertaken by the home to assist in identifying potential risks. Notifiable incidents are not always fully reported to the Commission. It is required that details of notifiable incidents are reported as required by the standards. Hethersett Hall DS0000048257.V319618.R01.S.doc Version 5.2 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 3 X 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 4 X 2 X X X 4 STAFFING Standard No Score 27 X 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Hethersett Hall DS0000048257.V319618.R01.S.doc Version 5.2 Page 22 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 OP9 Regulation 13.2 Requirement Repeated 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 Commission is to be notified of all serious complaints incidents and occurrences with detail as required in Regulation 37 of the Care Home Regulations. Service user access to the call system in their rooms in the Garden House must be individually risk assessed and provided as appropriate. Timescale for action 31/12/06 2. OP16 OP38 37 31/12/06 3. OP22 OP38 16 c 31/12/06 Hethersett Hall DS0000048257.V319618.R01.S.doc Version 5.2 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. 7. 8. Refer to Standard OP1 OP7 OP12 OP15 OP16 OP29 OP33 OP38 Good Practice Recommendations The Service User Guide could be made more accessible to service users with dementia care needs New care plans should be completed as soon as possible, with duplicate handover notes ceased when in place. Activities should be displayed in the Garden House in a way that supports access by service users with dementia care needs. The daily menu should be displayed in the Garden House in a way that supports access by service users with dementia care needs. The home should record and audit comments, compliments and suggestions made with action taken to assist in monitoring service user satisfaction. The home should apply the recommendations of “Safe and Sound” to its recruitment and vetting procedures. The Quality Assurance System should be developed according to the Care Standards so that the home becomes fully self-auditing and monitoring. The home should make a more detailed audit of accidents and occurrences in order that patterns and trends can be identified and preventative action taken. Hethersett Hall DS0000048257.V319618.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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.V319618.R01.S.doc Version 5.2 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. 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!