Inspection on 02/05/07 for Shouldham Hall Nursing Home

This inspection was carried out on 2nd May 2007.

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

Shouldham Hall Nursing Home 19/10/06

Shouldham Hall Nursing Home 28/06/06

Shouldham Hall Nursing Home 23/02/06

Shouldham Hall Nursing Home 03/08/05

Shouldham Hall Nursing Home 22/06/05

Shouldham Hall Nursing Home 16/11/04

Shouldham Hall Nursing Home 08/07/04

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 Shouldham Hall Nursing Home Shouldham Norfolk PE33 0DF Lead Inspector Kim Patience Key Unannounced 2nd May 2007 11:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Shouldham Hall Nursing Home DS0000015681.V338684.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. Shouldham Hall Nursing Home DS0000015681.V338684.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shouldham Hall Nursing Home Address Shouldham Norfolk PE33 0DF 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) 01366 347276 01366 347658 shouldham@btconnect.com Shouldham Hall (Registration) Limited Position vacant Care Home 48 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (34), Old age, not falling within any other of places category (14) Shouldham Hall Nursing Home DS0000015681.V338684.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To accommodate forty-eight (48) people in total, all of who are older people. Of these, thirty-four (34) Service Users will fall in the category of dementia and fourteen (14) Service Users will have needs associated with old age, not falling in any other category. One Service User under the age of 65 years who has dementia and is named in the Commission`s records may be accommodated. 19th October 2006 2. Date of last inspection Brief Description of the Service: Shouldham Hall is a 48-bedded care home with nursing for the elderly, and elderly mentally frail. The home consists of two wings, the original hall, and the new wing. There are a total of 44 single rooms and 2 double rooms on the ground and first floors. The home receives its medical services from the local G.P. centre. There is an enclosed garden and large grounds, and ample car parking on the front drive to the home. The home is situated at the edge of the village of Shouldham, which is 10 miles from Kings Lynn. The fees charged at this home range from £393 - £525 Shouldham Hall Nursing Home DS0000015681.V338684.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection includes pre-inspection information supplied by the home and a site visit taking approximately 7 hours to complete. During the site visit, several residents and one relative were spoken with and three staff were interviewed. Records relating to residents, staff and the business were examined and observations of staff and residents engaged in their daily activities were made. The acting manager and the operations manager were present throughout the inspection and helpful in facilitating the process. What the service does well: What has improved since the last inspection? • • • • • • • • • The home has sustained the improvements made at the last inspection and this is good. Care plans and associated records have been developed and now provide good information about peoples holistic needs. A new activities organiser has been appointed and has made good progress in the provision of person-centred activity. Mealtimes have been improved with the introduction of two sittings. People needing assistance to dine were provided with one-to-one support, which was given in a discrete and sensitive manner. A new training coordinator has been appointed and has made good progress with staff training. Improvements have been made to the fabric of the building. Improvements have been made to the laundry arrangements, care staff are no longer responsible for laundry after 9pm. The home now has a sensory garden. DS0000015681.V338684.R01.S.doc Version 5.2 Page 6 Shouldham Hall Nursing Home • Quality audit tools are now being used and the home aims to achieve a status of self-audit by the end of the year. 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. Shouldham Hall Nursing Home DS0000015681.V338684.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 Shouldham Hall Nursing Home DS0000015681.V338684.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): 3 Quality in this outcome area is good. The home can provide sufficient evidence that people wishing to use the service have their needs assessed and are provided with adequate information to make a decision as to whether the service can meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a policy and procedure for the admission of new residents that remains unchanged since the last inspection. People are invited to view the accommodation and have their needs assessed before agreeing to provide a service. People are provided with a brochure pack containing information about the facilities and services, which has been updated recently. Shouldham Hall Nursing Home DS0000015681.V338684.R01.S.doc Version 5.2 Page 9 Pre admission assessments were seen in resident’s files and contained basic information from which to assess the person’s suitability for the home and to ensure the home is able to meet their needs. The home does not offer intermediate care services. Shouldham Hall Nursing Home DS0000015681.V338684.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is good. The home can provide sufficient evidence that people’s care, health and social needs are now fully assessed and met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three care plans were inspected in Marham wing and three in Bexwell wing. At the last inspection there was a marked improvement in care planning and risk assessments. This inspection showed that the home has continued to improve the standard of care plans, health assessments and risk assessments and this is good. Assessments now contain good information about the individual’s needs and how they should be met. They consider people’s expectations and preferences and are person-centred. Care plan evaluations have been completed monthly and the home has conducted self-audits to ensure the standard is being maintained. Shouldham Hall Nursing Home DS0000015681.V338684.R01.S.doc Version 5.2 Page 11 The home now has care plan and risk assessment summaries in residents rooms so that care staff have easy access to the information they need and this is good. Staff spoken with said that they found the care plans to be informative and much improved, subsequently the outcomes for people who use the service are much better and this is good. Staff have worked very hard over a relatively short period of time to improve care plans to this extent are to be commended for their efforts. In addition, the barriers between nursing staff and care staff are reducing, resulting in a team that works together to achieve best outcomes for the people who use the service. Medication arrangements were inspected in brief. However, sufficiently enough to determine that the arrangements are safe and the home has introduced self-audits to ensure that good standards are maintained. Shouldham Hall Nursing Home DS0000015681.V338684.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. The home can provide sufficient evidence that peoples social and emotional needs are assessed and met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents files inspected contained information about life history, hobbies and interests. Each resident has an individual plan of activity that is drawn from the information held. Records of activity provided are maintained and show that people are provided with individual one to one and group activity. The home has appointed a new activities coordinator who was interviewed during the inspection. He discussed the progress he has already made with activities and had some good ideas about how to provide meaningful activity for people with dementia. He had drawn ideas from a variety of sources and this is good. During the inspection activities were observed, some people were doing colouring and some were engaged in one to one conversations. Shouldham Hall Nursing Home DS0000015681.V338684.R01.S.doc Version 5.2 Page 13 Many visitors were seen to come and go during the day without restriction. Staff were observed to be welcoming and friendly putting visitors at ease. The mealtime experience was observed and further improvements could be seen. The mealtime is now provided in two sittings, the first for people who need very little support to dine and the second for those that need full assistance to dine. Some residents were dining in their rooms and in the lounge area, which shows choice is offered. Menus are displayed on blackboards close to the dining areas. However, there were no menus on the dining tables to remind people of their meal choices on the day and the home could make improvements here. When discussed with the acting manager she said they had tried picture menus, but felt they were unsuccessful. Where possible, peoples likes and dislikes in respect of food are now noted in their care records. This information is given to the kitchen staff so that it can be taken into account when planning menus and providing meals. Menus show that one choice is offered for the main meal, however at lunchtime alternatives were provided. Breakfast and teatime menus show much more choice is offered at these times. On the day of inspection meals were served from a hot trolley brought into the dining room and the assistant serving the meal was seen to refer to records of people’s choices before serving the food, indicating that peoples dietary needs and preferences are considered. Residents appeared to enjoy their meal and were provided with appropriate support. The meal looked appetising and well presented. People who required full assistance to dine were given the support in a discrete and sensitive manner. Each person had a dedicated care assistant who sat with them throughout the meal and this is good practice. Care assistants could make further improvements to the mealtime experience for these individuals by recognising the need for good communication during dining. Shouldham Hall Nursing Home DS0000015681.V338684.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 and 18 Quality in this outcome area is good. The home can demonstrate that people who use the service can be confident their complaints will be taken seriously and that the home has systems in place that serve to protect peoples health and welfare. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has policies and procedures in place for dealing with complaints. The complaints procedure is well publicised and people spoken with knew how to raise concerns. The home has a comments box and have reinstated resident/relative meetings to provide an opportunity for people to raise any issues or concerns. In addition, the quality assurance system provides an opportunity for people to state where they think the service needs to be improved. There has been one complaint and one adult protection matter since the last inspection. Both were investigated appropriately with satisfactory outcomes. All staff are now receiving adult protection training and are aware of the whistle-blowing procedures. Shouldham Hall Nursing Home DS0000015681.V338684.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 and 26 Quality in this outcome area is adequate. The home provides a fair standard of accommodation with an ongoing plan of maintenance and renewal. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the premises was completed. All areas were found to be clean and tidy with no significant offensive odours apart from one room that was entered. This was highlighted during feedback and the home agreed to address the issue without delay. Shouldham Hall Nursing Home DS0000015681.V338684.R01.S.doc Version 5.2 Page 16 Marham wing is in need of some redecoration and refurbishment. However, the home has a plan in place for this to be addressed in the coming months. Residents rooms are to be redecorated and new curtains and quilt covers to be installed. Residents have been given the opportunity to choose the colour they wish to have from a sample board and this is good. Resources have already been allocated for the refurbishment and the home is awaiting the availability of decorators. Some work has already been completed in Bexwell and the environment is much more homely. 7 rooms have been redecorated in Rose wing and new furniture has been purchased. The hallway in Rose wing has also been redecorated. In Bexwell, the home should consider reducing the amount of laminated flooring and adding carpet to some communal areas to create a more homely feel. In addition, carpet would help to reduce the noise levels. Improvements to dining areas have been maintained and continue to provide a recognisable environment that is consistent with dining. This is particularly important for people with cognitive impairments. The home now has a sensory garden for people living in Bexwell, which will benefit resident’s, it is a safe area that is used for gardening activity. Residents are able to venture outside independently and this is good. The home has gardens at the rear that are not currently used and would be of benefit to people if accessible. Therefore it is recommended that the home makes the gardens safe and accessible for use. See recommendations. The home has made improvements to the laundry arrangements. Two laundry assistant are now employed to cover laundry between 9am and 9pm. Laundry is no longer dealt with by care staff after 9 o’clock in the evening as before. This allows staff to concentrate on providing care and is a positive change. Shouldham Hall Nursing Home DS0000015681.V338684.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 and 30 Quality in this outcome area is good. The home can demonstrate that people who use the service have their needs met by a competent workforce. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staffing rotas provided by the home show that the target staffing levels have been maintained. On the day of inspection there was no evidence to suggest that staffing levels were inadequate and that peoples needs were not being met. However, staff interviewed said that at times the staffing levels were not always adequate and they were under pressure, particularly in the afternoons. This had been raised at team meetings, but the management feel that the levels are adequate. It is recommended that the home review the staffing levels at the times when staff say it is difficult to manage and assess whether peoples needs are being met at these times. See recommendations. Shouldham Hall Nursing Home DS0000015681.V338684.R01.S.doc Version 5.2 Page 18 The provision of training continues to improve and the home has a training plan for 2007. A new training officer has been appointed and has made further improvements. The home produces a monthly statutory training record, which shows annual mandatory training and the percentage of staff that have completed it to date. At April 2007, the record showed that 50 of staff had completed basic food hygiene, 65 moving and handling, 74 abuse awareness and 67 fire safety. The homes target is to achieve 100 of all staff updated in mandatory training by July 2007. Staff are now being offered the opportunity to undertake an NVQ and although the home currently only has one care assistant qualified to NVQ level 2, 36 are in the process of completing an NVQ 2 and 10 completing an NVQ 3. Staff interviewed said that the training opportunities had improved and were now good. This shows that the organisation values its staff and recognises the importance of good training in driving up standards of the service. The organisation intends to introduce pay awards to recognise staff achievements and this will act as an incentive for staff to undertake training and also add value to the work that they do. Staff files were examined and evidence of training could be seen. In addition, files showed that recruitment practice was robust and conducted in accordance with the requirements of the regulations. However, the home must ensure that when staff commence work with two written references and a POVA check prior to the Criminal records check being returned, they are supervised by a named worker. See recommendations. Shouldham Hall Nursing Home DS0000015681.V338684.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36 and 38 Quality in this outcome area is good. There are systems in place to ensure that the home is managed in a way that considers the best interests of the people who use the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection the registered manager has resigned and the deputy manager has taken the post of acting manager. The home will be submitting an application for registration in the near future. Shouldham Hall Nursing Home DS0000015681.V338684.R01.S.doc Version 5.2 Page 20 The home has continued to make improvements to the management systems. Audit tools have been introduced and serve to ensure that good standards are met. For instance, the home has a quality audit tool for service user records and for medication. The operations manager has continued to conduct regulation 26 visits and provide regular monthly reports. The quality assurance mechanisms are in place and the home continues to consult with people who use the service to identify areas for improvement. The home has produced a business plan, which sets out their priorities for the next 12-24 months. This includes a proposal to introduce an incremental pay structure to recognise staff training achievements and this is good. In addition, there is a goal for the home to achieve a status of total self-monitoring by the end of 2007 and again this is good practice. The management of residents’ finances was checked and found to be in good order. The operations manager carries out random checks during the regulation 26 visits and this is a further safeguard. A plan of staff supervision is now in place and staff interviewed confirmed that they have regular supervision and support sessions including peer group supervision. All supervision is documented and stored in the staff files. The home continues to have systems in place for monitoring health and safety, risk assessments are written and reviewed and other health and safety checks are being completed in accordance with the regulations. An environmental health inspection was completed in March 2007 and no issues were identified. Shouldham Hall Nursing Home DS0000015681.V338684.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X X X X N/A 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 X X X X X X 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 X 3 X 3 3 X 3 Shouldham Hall Nursing Home DS0000015681.V338684.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 2 3 Refer to Standard OP19 OP27 OP29 Good Practice Recommendations People who use the service would benefit from access to the rear garden. People who use the service must be assured that their needs will be met by adequate numbers of staff. People who use the service should be assured that systems are in place to protect their health and welfare. Shouldham Hall Nursing Home DS0000015681.V338684.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 Shouldham Hall Nursing Home DS0000015681.V338684.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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