Inspection on 09/06/05 for Quebec Hall Christian Eventide Home

This inspection was carried out on 9th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Quebec Hall Christian Eventide... 10/04/07

Quebec Hall Christian Eventide... 01/10/05

Quebec Hall Christian Eventide... 13/01/05

Quebec Hall Christian Eventide... 12/10/04

Quebec Hall Christian Eventide... 25/03/04

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Bilney Hall

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Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Quebec Hall Quebec Road Dereham Norfolk NR19 2QY Lead Inspector Ruth Hannent Announced 9 June 2005 9.30am th 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. Quebec Hall I55s27266quebechallv223851090605(4).doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Quebec Hall Address Quebec Road Dereham Norfolk NR19 2QY 01362 692504 01362 692504 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) Quebec Hall Limited Mr Peter Tuckwell Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Quebec Hall I55s27266quebechallv223851090605(4).doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th Janiuary 2005 Brief Description of the Service: Quebec Hall Trust is a Christian Eventide home providing personal care and accommodation for twenty older people and has a strong Christian ethos.The home is in an attractive Georgian building situated on the outskirts of the market town of Dereham, where all local facilities can be found. Within the grounds there are forty-three bungalows providing sheltered housing, although these are not part of the registration.The building has three storeys and offers accommodation for twenty service users in fourteen single and three double bedrooms, two of which are occupied as singles at present. There is a passenger and three stair lifts, two lounges, a dining room and attractive, accessible gardens, with garden house and toilet, which is easily accessed. Quebec Hall is not suitable for service users with severe mobility problems, as a consequence of the frequent change in floor levels. Quebec Hall I55s27266quebechallv223851090605(4).doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over a period of 5 hours. Assisting the Inspector was Mr and Mrs Tuckwell the Registered Managers, Mrs Karen Vertigan Deputy Manager and Mr. Andrew Jessop Assistant Manager. A tour of the premises both inside and out took place. 10 residents were spoken to either in a group or in their own bedrooms. 2 staff members were spoken to A meal was taken in the dining room with the residents. Records of care plans, recruitment files, risk assessments and fire records were looked at. What the service does well: What has improved since the last inspection? What they could do better: Quebec Hall I55s27266quebechallv223851090605(4).doc Version 1.30 Page 6 The Home could ensure that all doors are fitted with self closers to safe guard the residents in the event of a fire. 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. Quebec Hall I55s27266quebechallv223851090605(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 Quebec Hall I55s27266quebechallv223851090605(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) 3,4 and 5 People receive a good assessment of need ensuring the needs can be met. Clear information and an open door for visitors ensures a full picture of care needs can be met. The whole staff team are proactive in involving and encouraging people to visit Quebec Hall to check for suitability. EVIDENCE: The most recent person to arrive at Quebec Hall had a full assessment of need on file (Seen). This had been completed by the Manager and was used as a starting point for the care plan. On talking to the residents throughout the day (most of them had lived there for many years) they had made their own decisions about moving to Quebec Hall. They knew about the Hall through brochures and talking to people involved with the Home. The Manager was able to give a clear picture of the care service that can be offered especially the need for mobility due to the type of building Quebec Hall is. Quebec Hall I55s27266quebechallv223851090605(4).doc Version 1.30 Page 9 People are encouraged to visit and in fact quite a few residents knew the Home before, through visiting others prior to their own need for residential care. Quebec Hall I55s27266quebechallv223851090605(4).doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 and 9 Good comprehensive care plans are in place to ensure the correct care is available to residents. Administration practice needs to be looked at carefully to ensure the full procedure is followed correctly. EVIDENCE: The care plans are written and reviewed by the Manager and Deputy Manager. 2 care plans were looked at in detail showing a clear picture of need for the individual person. Both these care plans had been dated and signed by the resident. On talking to one of the residents the detail in the care plan was the care this lady required, from the personal care to the social and health needs. All service users have a locked cabinet in their bedrooms to hold medication if they so wished. One lady had recently asked for the Home to help her with her medication as she was finding it difficult. The Home does have a policy (Seen) for people who wish to self medicate but no one is doing so at present. The administration of medication was observed at lunchtime with charts being signed before the resident had taken the tablets. (Requirement) This was Quebec Hall I55s27266quebechallv223851090605(4).doc Version 1.30 Page 11 discussed with the Manager and the member of staff who understood what she had done wrong. In conversation with all parties this was completely out of character and is not normal practice. Quebec Hall I55s27266quebechallv223851090605(4).doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13 and 15 Residents lifestyle requirements are met well and their social, religious and recreational needs are suitably met for their Christian beliefs. Residents are encouraged and do maintain contact with all people involved in their lives. Residents are offered a well balanced and wholesome meal to ensure a nutritional diet is offered at all times. EVIDENCE: All residents spoken to could not praise the Home highly enough for the lifestyle they lead. Due to the Christian beliefs of people who enter the Home the social, recreational and religious interests are met well by a team of staff who are mostly Christian themselves. During the morning, activities were held in the lounge with a lively conversation taking place with seven residents. One gentleman was departing to his computer class and one lady was off to the local shops on one of the Homes electric scooters. Throughout the day of the inspection a constant stream of visitors were coming and going. Each one was welcomed warmly and offered hospitality. The complex of bungalows at the side of the Hall offers a community feeling with neighbours popping in and out of the Home and taking part in meetings Quebec Hall I55s27266quebechallv223851090605(4).doc Version 1.30 Page 13 held on Thursdays and Sundays. One resident in her room keeps in contact with her family by a phone by her bed as they live far away and are unable to visit regularly. A meal was taken with residents in the dining room. The main course was offered on a plate with all vegetables in a serving dish with fresh new potatoes, cauliflower and green beans. Some residents had chosen an alternative with one having minestrone soup, another with chicken soup and a plate of vegetables and another with ham and vegetables. People at the table knew in advance what was on offer and knew if they did not like it they could choose an alternative. Quebec Hall I55s27266quebechallv223851090605(4).doc Version 1.30 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 The Home is aiming to ensure all staff are clear about abuse for residents protection. EVIDENCE: The Home has a very clear whistle blowing policy and written on the pre questionnaire were plans for all staff to attend training in the Protection of Vulnerable Adults. The Deputy Manager explained that during staff meetings policies such as whistle blowing will be discussed too ensure the policies are put in to practise. Quebec Hall I55s27266quebechallv223851090605(4).doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 and 26 Residents live in a well maintained environment but concerns are shared regarding the safety if there was a fire. The Home is very clean, pleasant and hygienic making it a nice environment to live in. EVIDENCE: The Home had a kitchen inspection from the Environmental Health Officer the week previous to this inspection and had been given a clear report. Due to the age of the Home the maintenance of the Home is constantly reviewed with the Manager and Trustees to keep this listed building in good condition. Some windows are to be replaced at the front upstairs of the building, once the new windows at the back have been completed. The home is furnished appropriately and decorated well. The latest Fire Officer report dated 21/10/04 showed everything was in order but on the day of this inspection some doors were seen wedged open and could be seen as a risk to residents. (Requirement). Quebec Hall I55s27266quebechallv223851090605(4).doc Version 1.30 Page 16 The Home is kept very clean and odour free. It was noted that a carer was helping a resident to clean her room at the same time as care was offered. The interaction between the two was heard with laughter and enjoyment. Quebec Hall I55s27266quebechallv223851090605(4).doc Version 1.30 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 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) 29 and 30 Although the Home does have a good recruitment procedure the storing of personnel files needs to be improved and all induction paperwork needs to be signed and dated. The Home is working towards getting the staff trained to build their skills EVIDENCE: Two staff files were looked at of two of the most recent recruits. One file had all the correct paperwork and seen was the application, two references and the CRB check. The induction programme was also in the file but had not been signed to show the programme had been completed (Recommendation) The other file had no references and were filed elsewhere, although these were not seen. (Recommendation). The Deputy Manager explained that all staff are shadowed until the CRB clearance has been received. At present 3 carers have completed their NVQ2. One lady has a BTEC qualification. 2 carers are in the process of NVQ2 and hope to complete in the next few weeks. Out of a staff of 24 this does not meet the 50 of staff qualified. (Requirement) One member of staff spoken to is keen to move from completing 2 this summer to advancing on to NVQ3 as soon as possible. The Deputy Manager is their assessor and working with the team to get them through. The pre inspection questionnaire gave a full programme of training that had taken place over the past 12 months with certificates seen of the recent fire training event with all the staff names who had attended. This event happens every six months to ensure all staff attend at least one of the dates. Quebec Hall I55s27266quebechallv223851090605(4).doc Version 1.30 Page 18 Quebec Hall I55s27266quebechallv223851090605(4).doc Version 1.30 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 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 33 This Home is managed and run well by a team of Managers who are able to deliver a good service. To aid the service further the management team need to expand the quality monitoring system to obtain views from all the people involved with Quebec Hall. EVIDENCE: The Registered Managers have been at the Home for many years and are competent and experienced. They do not hold the relevant management qualification and do not intend to as they are very near to retirement. The Deputy Manager is in the process of completing the required qualification with the intention of hopefully moving into the Registered Managers role when the present Managers retire. The Management team work very closely together and it was noted how they discuss all aspects of the Home and how actively they are all involved. Quebec Hall I55s27266quebechallv223851090605(4).doc Version 1.30 Page 20 The Home does have a questionnaire that is offered to residents to assist with the monitoring of quality. At present the families, friends, medical professionals or any regular visitors to the home do not have input in filling in questionnaires nor is feedback from questionnaires offered to the public as part of information sharing. (Requirement). Quebec Hall I55s27266quebechallv223851090605(4).doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 2 x x x x x x 3 STAFFING Standard No Score 27 x 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 2 x 2 x x x x x Quebec Hall I55s27266quebechallv223851090605(4).doc Version 1.30 Page 22 No 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 OP9 Regulation 13 Requirement The Registered person must ensure that the procedure for administering medication is followed. The Registered person must ensure that the fire doors throughout the building are kept closed or a self closer fitted.which would be triggered in the event of the fire alarm sounding. The Registered person must ensure that 50 of the care staff are trained to NVQ level 2 or equivalent. The Registered person must actively seek the views of all people involved with the Home as part of the quality monitoring process. Timescale for action Immediate and ongoing Immediate and ongoing 2. 19 23(4) 3. OP28 18 December 31st 2005 August 31st 2005 4. OP33 24 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 29 Good Practice Recommendations The Registered person is recommended to ensure all I55s27266quebechallv223851090605(4).doc Version 1.30 Page 23 Quebec Hall 2. 29 recruitment and personnel files are stored in one place The Registered person is recommended to obtain the signature and date of staff on all induction and training paperwork. Quebec Hall I55s27266quebechallv223851090605(4).doc Version 1.30 Page 24 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 © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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