CARE HOMES FOR OLDER PEOPLE
Letheringsett Hall Letheringsett Near Holt Norfolk NR25 7AR Lead Inspector
Ann Catterick Unannounced 25 April 2005 13:00 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Letheringsett Hall I55 s27655 Letheringsett Hall v223462 (un) 250405 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Letheringsett Hall Address Letheringsett Near Holt Norfolk NR25 7AR 01263 713222 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Imperial Care Homes Limited Mrs Laura Smith Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Letheringsett Hall I55 s27655 Letheringsett Hall v223462 (un) 250405 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 20 Older People of either sex may be accommodated. 2. 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. Date of last inspection 10 January 2005 Brief Description of the Service: Letheringsett Hall is a care home providing personal care and accommodation for 20 older people. The home is owned by Imperial Care Home Limited 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 out 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. 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 I55 s27655 Letheringsett Hall v223462 (un) 250405 Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place on the 25th of April 2005 and was over a 5.5 hour period. Seventeen service users were accommodated on the day of inspection and the inspector was able to speak to many of the service users. The time was spent looking at several care plans, staff files and talking with management, service users and staff as well as a tour of the building and observations of the grounds What the service does well:
The plans of care for service users were clear and gave all of the information needed to ensure staff were aware of service user’s individual needs. The service users spoken to confirmed that their needs were being met in the home and spoke very favourably about the cares staff and management within the home. Staff were described by service users as kind and caring and always looked to ensure the care offered was provided in the least intrusive way ensuring peoples privacy and dignity was respected. Management were described as available and approachable always able to listen to any view or concerns a person may have. The food within the home was described as appetising and plentiful and positives comments were made about the cook. The menus seen were varied and nutritious. The environment is rather grand and the individual bedrooms seen were all of a reasonable or large size with quality furniture, fixtures and fittings. Many of the service users spend a lot of time in their bedroom and they had been personalised by the service users making them homely and inviting. The grounds are large and attractive giving additional communal facilities in the warmer weather. Letheringsett Hall I55 s27655 Letheringsett Hall v223462 (un) 250405 Stage 4.doc Version 1.30 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 I55 s27655 Letheringsett Hall v223462 (un) 250405 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Letheringsett Hall I55 s27655 Letheringsett Hall v223462 (un) 250405 Stage 4.doc Version 1.30 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 Prospective service users needs are assessed prior to admission to ensure that there needs can be met within the home. EVIDENCE: The manager always visits a prospective service user prior to admission but at this pre admission assessment the assessment is not formally written down. The assessment forms are completed on the day of admission and it has been recommended that these assessment forms be completed at the time of the assessment. Letheringsett Hall I55 s27655 Letheringsett Hall v223462 (un) 250405 Stage 4.doc Version 1.30 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 and 10 Care plans were comprehensive and included all of the information needed to ensure that staff were aware of the individual care needs of service users and how those care needs should be met. Service users health care needs were being met encouraging all service users to reach their full health potential. Service users were being treated in a way that promoted their privacy and dignity enabling service users to be cared for in the least intrusive and dignified way. EVIDENCE: Most of those care plans seen were user friendly and clear, offering all the information needed to enable the specific needs of individuals to be met. One care plan was less recent and recorded on an old form that was not so user friendly and it has been advised that this be transferred to the newer care plan format. A new service user’s care plan had not been completed and it was planned that this would be done in the very near future. Letheringsett Hall I55 s27655 Letheringsett Hall v223462 (un) 250405 Stage 4.doc Version 1.30 Page 10 All service users spoken to felt that their health needs were being met. The home has a good relationship with all of their local community health care colleagues. Service users said that carers respected their privacy and dignity. Examples given were that staff would always knock on bedroom doors and offer personal care in the least intrusive way. Within care plans it was noted when service users wanted a bath and whether or not they preferred the carer in or out of the bathroom. Similar specific details about how and what care was preferred by the service user were seen on the care plans. The manager said that service users and/or relatives were involved in the creation of the care plan but there was no evidence of this on the care plans. Letheringsett Hall I55 s27655 Letheringsett Hall v223462 (un) 250405 Stage 4.doc Version 1.30 Page 11 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 and 14. The service users appeared to be satisfied with the lifestyle that they had within the home and this appeared to be meeting their social, cultural, religious and social needs. Service users are encouraged to keep in contact with relatives and friends and visitors are always welcomed within the home. Service users are encouraged to make decisions and take control of their own lives whenever this is possible. EVIDENCE: Many of the service users spoken to spoke very positively about their lifestyles within the home praising staff, management and the environment. Some service users chose to spend most of their time in their rooms, preferring to have meals and see visitors in their bedrooms whilst others preferred to eat some of their meals in the dining area and use the communal facilities. Some service users used the local church and other had communion within the home on a regular basis. Some activities are offered within the home and there are other links with the local community. There is opportunity for further development in this area. Letheringsett Hall I55 s27655 Letheringsett Hall v223462 (un) 250405 Stage 4.doc Version 1.30 Page 12 Service users said that their relatives were made welcome and a visitor confirmed this view. Many of the service users within the home are quite independent and are able to make day-to-day decisions that affect their daily life. Some of the service users spoken to were less independent and these service users were encouraged to make as many decisions as possible about their daily lives. Some of these areas were highlighted within the care plans. Letheringsett Hall I55 s27655 Letheringsett Hall v223462 (un) 250405 Stage 4.doc Version 1.30 Page 13 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 The home has a policy and procedures for the protection of vulnerable adults and evidence was seen to confirm that these policies and procedures had been followed when appropriate. EVIDENCE: The home has a policy and procedures for the protection of vulnerable adults. The procedure had recently been followed and paperwork relating to this was seen and all procedures had been followed correctly. When speaking to staff they had an understanding of these procedures and said they would be confident to whistleblow if need be and felt that they would be listened to. Service users spoken to felt that the manager and the care manager were very caring and approachable and if they had any concerns would always be comfortable to talk to them. Letheringsett Hall I55 s27655 Letheringsett Hall v223462 (un) 250405 Stage 4.doc Version 1.30 Page 14 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,23,24 and 26 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 needs of all service users. The home is kept clean and tidy with no offensive odours offering a pleasant environment for service users to live. EVIDENCE: The home and garden are well maintained and those service users spoken to were very comfortable within the environment. The home has 16 single rooms, 14 of which are en suite and two double rooms, both en suite. Two of the bedrooms are up a rather steep staircase with a stair lift and these are only offered to service users who are physically
Letheringsett Hall I55 s27655 Letheringsett Hall v223462 (un) 250405 Stage 4.doc Version 1.30 Page 15 and mentally able to use and be safe within the environment. The two service users that are living in this area were very satisfied with their accommodation and enjoyed their private surroundings. All other bedrooms seen were decorated and furnished to a high standard being individualised by the service users who lived in them. The quality of the bedroom facilities is commendable. All areas of the home seen were clean and tidy. Letheringsett Hall I55 s27655 Letheringsett Hall v223462 (un) 250405 Stage 4.doc Version 1.30 Page 16 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 28, 29 and 30. All required information needed to ensure that staff are suitable to work with vulnerable adults is collated before a member of staff commences employment as part of the recruitment and selection process of the home. Staff receive the appropriate training to enable them to carry out their duties thus providing a good quality of care to the service users. EVIDENCE: The staffing numbers within the home are adequate and service users said that there were enough staff at the home to meet their needs. The home has a thorough recruitment and selection process that ensures that all of the information required about staff is gathered. References are not dated as to when they are received and this means that there is no written evidence that references were received prior to the commencement of staff starting work. A recommendation has been made in this area. A recently appointed member of staff was spoken to and she was satisfied with the induction and training she had received. She had completed an induction that included working alongside the care manager for two weeks as well as having training relating to fire safety, adult protection, manual handling and food hygiene.
Letheringsett Hall I55 s27655 Letheringsett Hall v223462 (un) 250405 Stage 4.doc Version 1.30 Page 17 The home is in the process of training as many staff as possible to NVQ level 2. Letheringsett Hall I55 s27655 Letheringsett Hall v223462 (un) 250405 Stage 4.doc Version 1.30 Page 18 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 and 32. The home is well managed by an experienced manager. A care manager who also has a breadth of experience and knowledge oversees the day-to-day care. EVIDENCE: The manager is a qualified nurse and has significant experience in the care of older persons. She has not completed her registered managers award. The manager and care manager are competent and able having a good relationship Service users spoke very positively about the manager and care manager saying they were kind, supportive and approachable easy to talk to as well as being and good listeners. Letheringsett Hall I55 s27655 Letheringsett Hall v223462 (un) 250405 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x
COMPLAINTS AND PROTECTION 3 3 x x 3 4 x 3 STAFFING Standard No Score 27 x 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 3 3 x x x x x x Letheringsett Hall I55 s27655 Letheringsett Hall v223462 (un) 250405 Stage 4.doc Version 1.30 Page 20 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard 28 29 2 Good Practice Recommendations That the home aim to enure at least 50 of its staff are trainied to NVQ level 2 or its equivalent as soon as possible. That references are dated when received to enable clarification when looking to ensure that staff do not comence work until references are returned. That the assessemnt made by the home prior to the admission of a service user is formally recorded at that time and not recorded on the day of admission. Letheringsett Hall I55 s27655 Letheringsett Hall v223462 (un) 250405 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection 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
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