Inspection on 02/11/06 for Saxlingham Hall Nursing Home

This inspection was carried out on 2nd November 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

Saxlingham Hall Nursing Home 26/04/09

Saxlingham Hall Nursing Home 16/10/08

Saxlingham Hall Nursing Home 23/02/06

Saxlingham Hall Nursing Home 07/09/05

Saxlingham Hall Nursing Home 07/02/05

Saxlingham Hall Nursing Home 16/08/04

Saxlingham Hall Nursing Home 19/03/03

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 Saxlingham Hall Nursing Home The Green Saxlingham Nethergate Norfolk NR15 1TH Lead Inspector Mrs Marilyn Fellingham Unannounced Inspection 2nd November 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 Saxlingham Hall Nursing Home DS0000015679.V318883.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. Saxlingham Hall Nursing Home DS0000015679.V318883.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Saxlingham Hall Nursing Home Address The Green Saxlingham Nethergate Norfolk NR15 1TH 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) 01508 499225 01508 499612 staff@saxlinghamhall.fsnet.co.uk Saxlingham Hall Nursing Home Limited Mrs Theresa Dawn Parfitt Care Home 41 Category(ies) of Old age, not falling within any other category registration, with number (41) of places Saxlingham Hall Nursing Home DS0000015679.V318883.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd February 2006 Brief Description of the Service: Saxlingham Hall is a large detached house dating back to 1880, and is situated in about two and a half acres in a rural setting, about two miles from the centre of the village of Saxlingham Green. Accommodation is on two floors with both floors being accessible to wheelchair users. Service users accommodation is provided within thirty-one single bedrooms and four double rooms, with the majority having en-suite facilities. The bedrooms are situated on both floors with access by two shaft lifts. All rooms have a television and telephone point. On the ground floor is a large lounge and dining room, with a further two small sitting rooms, and a conservatory leading out to the patio area overlooking spacious garden and woodland areas. There are ample parking places. Saxlingham Hall Nursing Home DS0000015679.V318883.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over five hours. Opportunity was taken to tour the premises, look at care and staff records, talk to staff members and service users. The home has taken the opportunity to address many of the issues that were highlighted in the last key inspection. What the service does well: What has improved since the last inspection? The kitchen has been totally re furbished. Recruitment records have much improved with all necessary checks and records in place. The frequency of formal supervision sessions have been increased and now all members of staff receive these at least six times a year. Saxlingham Hall Nursing Home DS0000015679.V318883.R01.S.doc Version 5.2 Page 6 There has been much improvement in the process for recruitment. The home has made very good progress to achieving 50 of its care staff being qualified to NVQ 2 or above. The home has now established a system for monitoring the quality of the services it offers. 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. The summary of this inspection report can be made available in other formats on request. Saxlingham Hall Nursing Home DS0000015679.V318883.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 Saxlingham Hall Nursing Home DS0000015679.V318883.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): 1,2,3,4,5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users have adequate information to make an informed choice about admission to the home; they are informed by written confirmation whether their needs can be met. EVIDENCE: Case tracking of three recent admitted service users to the home confirmed good practice. The manager or her deputies visit prospective service users either in their homes or in hospital where a thorough initial pre admission assessment is carried out. Examples of these assessments were seen, they were very detailed and contained important information that the home then bases its decision on whether it can meet a particular individuals needs. Letters are sent to the prospective service users if the homes establishes it can Saxlingham Hall Nursing Home DS0000015679.V318883.R01.S.doc Version 5.2 Page 9 meet their needs and copies of these letters were seen. Those service users spoken to felt that they had been given sufficient information to enable them to make an informed choice about admission to the home. Contracts were seen for these service users. Saxlingham Hall Nursing Home DS0000015679.V318883.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): 7,8,9,10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The variations in content in some care plans means that service users cannot always be sure that their needs are fully met. The handling and administration of medication is managed well. EVIDENCE: Those service users spoken to said that they were very well cared for and that the staff were kind and caring and nothing was too much trouble. One service user commented that the staff were great and it was just like being at home. Staff have an overall understanding of the care needs of the service users, however more work is needed to ensure that all needs are recorded and evidence noted of care given. The homes medication policies and procedures are adhered to and have been revised. Although there has been in the past some discrepancies, these have been due to incorrect dispensing from the surgery. The home and surgery are aware of this and the home has a strict checking system in place. Saxlingham Hall Nursing Home DS0000015679.V318883.R01.S.doc Version 5.2 Page 11 Medication audits are carried out and stock is counted every ten days. Records for this activity were seen and where medication has not been recorded as given or refused, those members of staff who have been negligent in this activity are reminded of their responsibilities and notes for this were seen. Case tracking confirmed good practice and a random check of medication tallied with that medication remaining in stock. Saxlingham Hall Nursing Home DS0000015679.V318883.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users are well supported and encouraged to be in control of their lives. Activities and meals are managed well. EVIDENCE: Throughout the inspection process visitors were seen to come and go and those service users spoken to said that their visitors were always made welcome. The Inspector attended part of an exercise group that was being held in the afternoon; three staff members were also present with one of them leading the group. Staff were heard interacting with the service users and it was noted that they were helping the service users in a dignified and caring manner. It was evident that the service users enjoyed this activity and indeed this was the information gained after discussion with the service users. The activity programme was examined and indicated that many opportunities were offered to the service users to enable them to satisfy their social, physical and emotional needs. Discussion with service users confirmed that they enjoyed many of the sessions and that they particularly liked the reminiscence ones. Saxlingham Hall Nursing Home DS0000015679.V318883.R01.S.doc Version 5.2 Page 13 The Inspector observed lunch being served. The service users commented that they thought the food that they are offered is very good and that there were always choices to be made. It was noted that one resident needed pureed food, however the food had been pureed all together with no separation of meat and vegetables; it is recommended that the meat and vegetables be pureed separately. This is more appealing to those who are eating and considered good practice. Examination of the menus indicated that there was on offer an appealing and well-balanced choice of meals. Saxlingham Hall Nursing Home DS0000015679.V318883.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): 16,17,18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users feel safe and they feel confident that they are listened to. Service users financial arrangements are protected by the homes policies for dealing with resident’s monies. EVIDENCE: One complaint had been received by the home and detailed records indicated that it had been handled in a satisfactory way and had been resolved. A complaints procedure is available to all service users and given to service users on admission to the home. Those service users spoken to stated that they were aware of the procedure for making a complaint. One service user commented that although she knew she could speak to the Matron it had never crossed her mind to make a complaint as everything always ran so smoothly. The home does not handle any money on behalf of the residents as all items such as papers and chiropody is put on to an account and then settled by the appropriate agencies, relatives and service users if able. Saxlingham Hall Nursing Home DS0000015679.V318883.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): 19,20,23,24,25,26. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The overall ambiance of the home is most pleasant. The service users live in a safe and comfortable environment. EVIDENCE: The Inspector found the home to be very clean and tidy. Duty rosters indicated that there were always sufficient domestic staff on duty to ensure that the home was clean and hygienic. Many of the rooms have been re decorated as they are vacated, some of them have had the addition of level access showers and as others become empty they will also have the addition of these types of showers. A complete new kitchen has been installed bringing it in line with environmental recommendations. Saxlingham Hall Nursing Home DS0000015679.V318883.R01.S.doc Version 5.2 Page 16 There are plans to replace windows to ensure that more heat is retained for the service users benefit. Some re roofing has taken place and further insulation. It was noted that the room being used for the exercise group was exceptionally cold and it is recommended that this be attended to for future group activities. Those service users spoken to expressed satisfaction with their accommodation, there was evidence of personalisation of their rooms. Saxlingham Hall Nursing Home DS0000015679.V318883.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): 27,28,29,30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are well supported by skilled and knowledgeable staff. There is a robust system in place for recruitment. EVIDENCE: Those service users spoken to felt that they were very well supported by the staff and that they were also very well cared for; one service user commented that the staff were very good and that nothing was too much trouble and that their bells were answered quickly. The Inspector noted that on the day of inspection there was a very good skill mix of staff on duty; there were three Registered Nurses, the Matron and eight carers. The duty rosters reflected that this was the norm and that there was always sufficient staff on duty to meet the assessed needs of the service users. Records for newly appointed staff were examined and were seen to reflect a robust system for recruitment of staff. The files were also seen to contain appropriate proof of staff identity. Discussions with staff members confirmed that they were well supported in their roles and that they were given many opportunities to increase their knowledge in relation to being able to meet the needs of the service users. Saxlingham Hall Nursing Home DS0000015679.V318883.R01.S.doc Version 5.2 Page 18 New staff members have had induction sessions and these have been recorded. The matron is aware of her staff’s training needs and the staff are being fully developed particularly in relation to ensuring that the care staff meet the required ratio set out in the standards for NVQ 2 qualification or above. Saxlingham Hall Nursing Home DS0000015679.V318883.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): 31,32,33,34,36,37,38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Management of the home is good and meeting the needs of the service users. EVIDENCE: Staff and service users feel that the management team are all approachable and that they were always available to discuss any concerns that they might have. The home has started to introduce a quality monitoring system. Records were seen to establish that a system for formal supervision is in place and that this happens a minimum of six times a year. Saxlingham Hall Nursing Home DS0000015679.V318883.R01.S.doc Version 5.2 Page 20 Records were also seen relating to health and safety, these included audits for accidents, testing of new electrical equipment and testing of all new equipment brought into the home. Saxlingham Hall Nursing Home DS0000015679.V318883.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 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 x x 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 x x 3 3 3 Saxlingham Hall Nursing Home DS0000015679.V318883.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard 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. Refer to Standard OP19 Good Practice Recommendations The registered persons should ensure that all rooms used by the service users are kept at the required suitable temperature. The registered person should ensure that liquidised food is served in an appetising manner. 2. OP15 Saxlingham Hall Nursing Home DS0000015679.V318883.R01.S.doc Version 5.2 Page 23 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 Saxlingham Hall Nursing Home DS0000015679.V318883.R01.S.doc Version 5.2 Page 24 - 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. 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