Inspection on 22/02/06 for Letheringsett Hall

This inspection was carried out on 22nd February 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Letheringsett Hall 18/05/07

Letheringsett Hall 25/04/05

Letheringsett Hall 10/01/05

Letheringsett Hall 19/07/04

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 Letheringsett Hall Letheringsett Near Holt Norfolk NR25 7AR Lead Inspector Ann Catterick Unannounced Inspection 22nd February 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Letheringsett Hall DS0000027655.V272872.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Letheringsett Hall DS0000027655.V272872.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Letheringsett Hall Address Letheringsett Near Holt Norfolk NR25 7AR 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) 01263 713222 01263 713222 Imperial Care Homes Limited Mrs Laura Ellen Smith Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Letheringsett Hall DS0000027655.V272872.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 20 Older people of either sex may be accommodated Bedrooms numbered 3 and 4 on the first floor are only to be occupied by service users who are sufficiently physically and mentally able, to minimise the risk involved in needing to access these rooms utilising a chairlift. 25th April 2005 Date of last inspection Brief Description of the Service: Letheringsett Hall is a care home providing personal care and accommodation for 20 older people. Imperial Care Homes Limited owns the home and the Proprietors are Mr Steve Smith and Mrs Laura Smith. Laura Smith is the Manager of the home. The home is located in the village of Letheringsett, a mile outside of the historic town of Holt, and is close to all amenities. Letheringsett Hall provides quite grand accommodation and is set in spacious grounds with delightful views of the large grounds and surrounding countryside. Accommodation is provided on three floors providing 16 single rooms and 2 double rooms, most of which have en suite facilities. At the present time one of the double rooms is being used as a single room. The home has ample communal space and has a passenger lift to the first and second floor with a stair lift that services two separate bedrooms on the first floor. The home is well maintained throughout. Letheringsett Hall DS0000027655.V272872.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place on Wednesday the 22nd of February 2006 and lasted for 5hours. The Inspector was able to meet with the Proprietor and Proprietor Manager, service users, staff and some relatives, as well as have a tour of the building and inspect documents and files. Sixteen feedback forms were seen on the day of inspection, from service users, and some were also received from relatives prior to the inspection. Generally all comments were good. Some service users felt that there could be more activities but overall the feedback from these forms was positive. All staff spoken to appeared to be competent in their role and all service users were very positive about the care they receive. In conclusion the quality of care and the quality of the environment is very good. What the service does well: The environment is of good quality offering a delightful setting to live. All service users spoke positively about the care they received. “Well looked after and the food is very good.” “Staff very kind and well trained.” “Beautiful carers from the boss down.” The rota showed that the home is well staffed. Care plans were detailed and identified individual need. Letheringsett Hall DS0000027655.V272872.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Letheringsett Hall DS0000027655.V272872.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Letheringsett Hall DS0000027655.V272872.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 A prospective service user’s needs are assessed prior to admission to ensure that these needs can be met within the home. EVIDENCE: Four care plans were seen and these included the information gathered by the home prior to admission. The manager visits a prospective service user, prior to admission, to assess their needs and assess whether or not their needs could be met within the home. Several of the service users are admitted without involvement from social services and self refer. When social services or health are involved assessments are received from these professionals. Letheringsett Hall DS0000027655.V272872.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 and 9 Service users health, social and personal care needs are assessed and identified within an individual care plan. The policy and procedure around all issues relating to medication are aimed to protect service users and keep them from harm. EVIDENCE: Several care plans were seen and these were comprehensive including all of the relevant information needed. All had a front page with photograph and basic details. The care plans are completed in detail with lots of information. The manager felt that the format was simple and easy for care staff to read. Care plans are reviewed on a regular basis. Those service users spoken to felt that there needs were being met. The home has a policy and procedure for the administration of medicines. Staff taking responsibility for the administration of medication have the appropriated training. The administration and recording of administration was observed and this was done in a competent way. Letheringsett Hall DS0000027655.V272872.R01.S.doc Version 5.0 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 and 15 The lifestyle experiences of service users matched their expectations and preferences. Service users are encouraged to maintain contacts with friends, family and other contacts within the local community. The food provided within the home is wholesome and appealing offering a balanced die to people in attractive surroundings. EVIDENCE: Several service users were spoken to and all felt that the service within the home matched their preferences and expectations. Several of the service users living in the home are quite independent and made the decision that the home would meet their needs prior to admission. Service users felt that they could control their own lives spending their time as they chose, either in their bedrooms or on the communal areas of the home. Five service users have specialised buggies that they can use to drive themselves around the grounds in the warmer weather. Service users are encouraged to make their personal space their own by having as many of their own belongings as possible in the home. Letheringsett Hall DS0000027655.V272872.R01.S.doc Version 5.0 Page 11 Service users said that relatives were always welcomed in the home. Visitors spoken to on the day of inspection confirmed this. Some service users maintain contact with local churches and clubs. On the day of inspection the lunch- time meal was seen and was of good quality and presented well. Service users can have an alternative meal if they did not like the first choice. The menu is in the main reception area for all to see and is varied offering lots of different meals. The cook said that she spoke to service users on a regular basis to ensure that they were happy with their meals and to ask for any suggestions or preferences for the menu. At teatime there is always a choice of a hot or cold meal. The cook ensures there are lots of homemade cakes. Tea, coffee, fruit and biscuits are available throughout the day. Service users spoke positively about the meals provided. It was good to see some service users had chosen to have wine with their lunch. Letheringsett Hall DS0000027655.V272872.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 The home has a policy and procedures to deal with complaints and this is made available to service users and their families. EVIDENCE: A copy of the homes complaints procedure is on display at the front of the home and is included within the Service Users Guide. The home has received no complaints since the last inspection. Service users spoken to say if they were to ever have any concerns they would be comfortable talking to the manager about these. Letheringsett Hall DS0000027655.V272872.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 24 The home is safe and well maintained offering good quality accommodation within delightful grounds that are accessible to service users. Service users bedrooms are varied in size and style and meet the individual needs and preferences of service users. EVIDENCE: Letheringsett Hall is a delightful property offering stylish comfortable accommodation. The home and garden are well maintained and those service users spoken to were very comfortable with their environment. The home has a large drawing room and an area with seating in the entrance to the home. There is an individual dining area that is comfortable and looks out onto the grounds. On the day of inspection there was a problem with a valve on the downstairs bathroom but this issue was being dealt with. The home has a handyperson and a service user spoke very positively about him saying he was always Letheringsett Hall DS0000027655.V272872.R01.S.doc Version 5.0 Page 14 willing to help hang pictures or do minor jobs. The home has a system for reporting repairs and the manager inspects the environment on a regular basis. The inspector, with permission, was able to view several bedrooms and these were of all different shapes and sizes offering original and comfortable accommodation. The inspector was able to speak to one of the service users who has a bedroom at the top of a fairly steep staircase that is only offered to service users with good mobility. The staircase has a chair lift. The service user was very satisfied with her room and found no problem with the stairs. All service users spoken to were very happy with their bedrooms and the quality of bedroom furniture has once again been commended. Letheringsett Hall DS0000027655.V272872.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 and 29 The number of staff on duty at any one time appears to be sufficient and staff appear to have the competence, knowledge and skills needed to meet the needs of service users. The homes has a policy for recruitment and selection of staff but some of the relevant documents needed for one member of staff had not been obtained or had been obtained but not translated into English. EVIDENCE: On the day of inspection staff were on duty in sufficient numbers to meet the needs of service users. Due to a service user’s change of needs the home had, in recent months, arranged that more staff be on duty at specific times to ensure that all service users needs were being met. This was seen as good practice. The rota was seen and this supported the view that staffing numbers were sufficient. Those staff spoken to felt that there was enough staff on duty at any one time. On the day of inspection staff were seen involved in activities with service users and offering one to one staff time. Staff receive appropriate training to ensure that they can fulfil the roles and responsibilities of their posts. The home has a recruitment and selection process that for most part is followed appropriately. The manager has appointed some staff from overseas and it was noted that CRB’ had not been applied for and that for one member of staff references had not been translated into English. These staff had Letheringsett Hall DS0000027655.V272872.R01.S.doc Version 5.0 Page 16 appointed through an agency but the manager still has the responsibility to complete all checks as identified in Schedule 2 of the Care Home Regulations 2001. A requirement has been made in this area. Letheringsett Hall DS0000027655.V272872.R01.S.doc Version 5.0 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35 and 38 The home is run in the best interests of service users. The home has systems in place to safeguard the finances of service users. The home has policies and procedures that aim to promote and protect the well being and safety of service users and staff. EVIDENCE: The manager has systems in place to receive feedback from service users and their families about different aspects of the home. The home uses some questionnaires and feedback forms, has service user meetings, staff meetings and regular formal staff supervision. All of this information is recorded and available. The manager now needs to publish the findings of this data and identify any action taken. Letheringsett Hall DS0000027655.V272872.R01.S.doc Version 5.0 Page 18 The manager encourages service users and/or their families to take responsibility for any monies. All service users are offered a lockable facility at the time of admission within the bedside cabinet. Some service users choose to have their own furniture and this sometimes means that they ask for the locked facility to be taken out of the room. The only money kept by the manager is small amounts of cash that is used for small personal items or hairdressing or chiropody. All transactions or recorded with receipts and countersignatures. The money is kept in the homes safe. It is kept altogether and not in separate purses or containers and a recommendation has been made in this area. All staff receive induction and foundation or NVQ training and all staff complete any mandatory training, for example, moving and handling, fire safety and food hygiene. All appliances and utility systems are serviced on a regular basis. The home stores its chemicals in a safe way All baths have safety values and on the day of inspection one of these was not working properly and a plumber was immediately called and the bath put out of action until repaired. All upstairs windows have window restrictors and all radiators are covered other than those in the lounge area. These have been risk assessed and are behind furniture deemed as safe but offering the best heating output to keep the large room warm. The manager risk assesses individuals and the environment. All accidents and incidents are recorded. In conclusion the manager provides a safe environment for service users to live and staff to work. Letheringsett Hall DS0000027655.V272872.R01.S.doc Version 5.0 Page 19 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 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 x 3 x x x x 4 x x STAFFING Standard No Score 27 3 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x 3 x 2 x x 3 Letheringsett Hall DS0000027655.V272872.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP29 Regulation 19 (4) Requirement The Registered Provider must ensure that all of the relevant documents regard staff are obtained prior to staff being offered employment within the home. Timescale for action 01/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP33 OP35 Good Practice Recommendations It would be good practice to collate and publish the findings from quality assurance systems. It would be good practice that when money is kept in safe keeping for service users it is kept in separate purses and not pooled altogether. Letheringsett Hall DS0000027655.V272872.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Letheringsett Hall DS0000027655.V272872.R01.S.doc Version 5.0 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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