Inspection on 29/06/06 for Walcot Hall

This inspection was carried out on 29th June 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

Walcot Hall 15/11/05

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 Walcot Hall Walcot Green Diss Norfolk IP22 5SR Lead Inspector Mrs Marilyn Fellingham Unannounced Inspection 29th June 2006 09:00 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 Walcot Hall DS0000065021.V302425.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. Walcot Hall DS0000065021.V302425.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Walcot Hall Address Walcot Green Diss Norfolk IP22 5SR 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) 01379 641030 01379 644511 Saxlingham Hall Nursing Home Limited Ms Susan Doherty Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Walcot Hall DS0000065021.V302425.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th November 2005 Brief Description of the Service: Walcot Hall provides nursing care for older people. The Home is situated in a small hamlet adjoining the market town of Diss. The original building is a two storey detached property built in the 18th. Century and has been extended to provide an additional wing of 18 beds. It is set in three acres of ground with a small lake in the lawned area of the gardens. The Home is accessible by road and the nearest rail station is in Diss. Parking is available in the small car park and adjacent road. There is a twice daily bus service from a near by bus stop into town. It would be beyond walking distance for older people. Walcot Hall DS0000065021.V302425.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Inspector arrived unannounced and spent over eight hours at the home. The views of the management, staff and a selection of service users were obtained; a tour of the Home was made and records were also examined and have helped inform the judgements made. Ten service user comment cards were received and three from relatives. The Home has attempted to address most of the issues highlighted in the last report and it is noted that the new owner and Matron have showed a good understanding of the areas of weakness since they took over the Home and there is a good capacity for the home to move forward. What the service does well: What has improved since the last inspection? Work has continued on improving all aspects of care, care plans are now in place and these reflect a good assessment process and are very informative. More refurbishment has taken place both internally and externally. Walcot Hall DS0000065021.V302425.R01.S.doc Version 5.2 Page 6 A robust system is now in place for recruitment purposes. Two new hoists with slings have been purchased. Many of the requirements that were issued in the last inspection report have been addressed. The process for administering, handling and disposal of medication has greatly improved. Cleanliness in the kitchen has improved, as has also the management of menus and the quality of food. Staffing levels have increased. The shift patterns have been changed giving better opportunities for teamwork, increasing communication and improving the care offered. 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. Walcot Hall DS0000065021.V302425.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 Walcot Hall DS0000065021.V302425.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3. The quality outcome for this group was good. EVIDENCE: Case tracking of two newly admitted service users confirmed good practice; both were visited at home by the Matron to assess their initial care needs and establish if they could be met. One husband looked round the home first, he stated that the staff and Matron were most helpful and gave him lots of pertinent information. Another service user said that she had been given most useful information and that everyone was very helpful. She also confirmed that she had been given a service user’s guide and contract. The Matron had explained everything to her. The service user’s guide was seen by the Inspector and it was most comprehensive and written in easy to understand language. The statement of purpose and the service user’s guide contained all aspects that result in compliance with these standards. Walcot Hall DS0000065021.V302425.R01.S.doc Version 5.2 Page 9 The Matron described the process for admission to the Home and stated that she or her deputy does the assessment. The written assessment documentation was good and most informative which allowed the formation of plans of care to ensure that all social, emotional and physical care needs could be met. Walcot Hall DS0000065021.V302425.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. The quality outcome for this group is good. EVIDENCE: Service user care plans were good with evidence of service user involvement, review and amendments when required. It was noted that there were detailed instructions for all care needs and nutritional and skin integrity assessments had been carried out and care prescribed accordingly; regular weight monitoring is also recorded. The care plans had clear guidelines for care in relation to mobility needs and manual handling; they also contained relevant prescribed care for those with some confusion. The Home’s medication policies are now being put into practice and there was evidence of discussion with Registered Nurses at staff meetings about their practice and adhering to the policies for handling and administering medication. Walcot Hall DS0000065021.V302425.R01.S.doc Version 5.2 Page 11 Registered nurses that the Inspector spoke with are aware of their responsibilities and conforming to the Home’s policy for medication. The records for receipt and disposal of medication were clear; records for weekly auditing of medication were also available for inspection. Theses highlighted some gaps on the MAR charts with no explanation why the medication had not been given, this was also noted by the Inspector when case tracking. This practice and lack of adequate recording has the potential to place the service users at risk. Three visitors were spoken to on the day of inspection; one said that her brother always looked well cared for clean and tidy. Another visitor said he felt his wife was well looked after and he was very satisfied with the care she was given. Staff have an overall understanding of the care needs of the service users in their care. The Registered Nurses felt that the care plans were much improved and one stated that she liked the system that was now in place that highlighted when care had been changed and that if one was away for a few days it was easy to pick up and facilitate care that had altered. This nurse also felt that because communication had improved greatly within the caring team important issues related to care were not missed, thus enhancing the overall care that the service users received. Walcot Hall DS0000065021.V302425.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. The quality outcome for this group is good. EVIDENCE: The last inspection visit (November 2005) set a requirement to ensure that the service users’ social and recreational needs are assessed and met. A plan has now been drawn up and various activities and outings are being arranged, these will give the service users the opportunity to be both active in the Home environment but also in the community. The matron stated that she is hoping to send one of the carers on a reminiscence course; the said carer when spoken to by the Inspector confirmed this. The carer also explained other activities and outings that had or were going to take place. Those service users spoken to said that they liked the outings and reminiscence sessions and one service users stated that she was aware of activities on offer but chose not to take part, as she liked spending time in her room reading. The Matron realises there is still much to be done in relation to ensuring the service users are able to participate in social activities, however much has already been addressed to ensure that this standard is met. Visitors spoken to during the inspection said that they were always made welcome especially since the new management had been in place. It was Walcot Hall DS0000065021.V302425.R01.S.doc Version 5.2 Page 13 noted that one visitor had been made a coffee by the staff and was enjoying sitting with their relative. Menus that were seen, offered a variety of well-balanced meals and one service user stated that the meals were now excellent, and another remarked that since the new owner had taken over the food had greatly improved. The Inspector observed lunch being served it was relaxed and those who did not wish to go into the dining room opted to have their meals served elsewhere. It was also noted that those persons who needed assistance were being helped in an empathetic way and the whole period seemed to be un rushed and sociable. Two cooks are now in place from the sister home and issues highlighted in the last report relating to hygiene and kitchen cleanliness have now been addressed and the most recent inspection report by the Environmental Health Officer was seen. The cleaning rotas were examined and it is recommended that signatures be made for all the cleaning activities and kept up to date. Walcot Hall DS0000065021.V302425.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. The quality outcome for this group is good. EVIDENCE: A new complaints procedure was in place and this was examined by the Inspector and found to be easy to read with clear instructions. Those service users spoken to stated that they knew how to make a complaint and also who to go to if they had any concerns. The general consensus from both service users and staff was that they felt able to speak to staff and stated that the new Matron was always available to discuss matters and listen; the comment cards also reflected this. Staff who were spoken to were aware of the complaints procedure. Staff spoken with were aware of issues related to abuse and of their responsibility to raise any concerns with the management of the Home. Walcot Hall DS0000065021.V302425.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,24,25,26. The quality outcome for this group is adequate. EVIDENCE: The home was found to be clean and tidy, one visitor commented that her relative’s room always smelt clean. The new owner has already undertaken some improvements with two rooms being completely restored with the addition of en suite facilities and new windows. The new provider and the Matron are aware of the cosmetic refurbishment that needs to be done and have prioritised the refurbishment programme to ensure that all service users rooms are adequate first and meet the criteria necessary to meet the standards. It was noted that the paintwork in the sitting room needs attending to. Ten rooms have been re carpeted and re decorated, the reception area has been greatly improved and appears very homely and welcoming. The front of the home around the pond is being landscaped and much water out of the pond has been drained and is now less deep. A gazebo Walcot Hall DS0000065021.V302425.R01.S.doc Version 5.2 Page 16 has been added to the sunken garden and it was noted by the inspector that a number of service users were enjoying being outside but protected from the suns harmful rays. A new fire panel has been placed in the downstairs corridor making the procedure for locating a fire safe. The Housekeeper shared with the Inspector that she felt that the workload for the domestic staff has changed for the better and since the new provider has taken over more domestic staff have been employed; she also felt that they were given better resources in order for them to their job more efficiently. Those service users spoken and relatives said that they were pleased with their rooms and one service user was very excited about returning to her very new refurbished room and could not wait to look out of the new windows that had been put in. Many of the rooms still need to be refurbished but as already discussed this is part of the overall development of the Home. The Inspector spoke with those residents that were part of the case tracking exercise and they were able to show her that their rooms had been personalised and one resident had been enabled to have her favourite dolls house in her room along with some cherished antique dolls. It was noted that there was no provision for the storage of wheelchairs and a recommendation is issued. New equipment is gradually being provided; two new hoists with new slings have been purchased, thus reducing the potential risk of using inferior equipment. Walcot Hall DS0000065021.V302425.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. The quality outcome for this group is good. EVIDENCE: The duty rosters were examined and showed that for all the shifts the Home had sufficient staff on duty. Those staff spoken with felt that the staffing situation had greatly improved and since the new shift pattern had been introduced they generally felt that they were able to more adequately meet the needs of the service users. One service user also commented that she felt that the care was much better since the shift patterns had changed. A Registered Nurse said that since the new ownership the staffing situation had improved and the new shift patterns had increased motivation and team work which had an improved impact on resident care. The Matron explained that one new RN and three carers had been employed since the last inspection and new domestic staff. Records for newly appointed staff were examined and were seen to reflect a robust checking system before staff are employed. The files were also seen to contain appropriate proof of staff identity. Discussions with staff show that they have a good understanding of their roles and feel supported by the new management. Walcot Hall DS0000065021.V302425.R01.S.doc Version 5.2 Page 18 Discussion with the new members of staff revealed that they had been given a rigorous induction that had also been recorded. A training plan is being developed and the Matron is aware of the training needs of the staff in order to meet the needs of the service users. All the staff spoken with said that they felt that the management were committed to improving the service and training. Walcot Hall DS0000065021.V302425.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,36,37,38. The quality outcome for this group is good. EVIDENCE: Those service users and visitors to the Home knew the new management construction of the Home and felt that it was being management much better than in the past. They also stated that the new Matron was very approachable and always available to discuss any concerns that they might have. Both service users and visitors commented that they were aware of many improvements since the new owner took over. Those staff spoken with were appreciative of the improvements that have taken place, especially in relation to communication and felt that the new matron was very approachable. Walcot Hall DS0000065021.V302425.R01.S.doc Version 5.2 Page 20 There is no system in place yet for monitoring the quality of care, however the Matron is aware of this need. Although the staff were adamant that they were well supported by the new management, there is no arrangement in place for formal supervision. Paperwork was seen for this and the Matron hopes to instigate it soon. Records for servicing appliances were seen and are up to date. The Matron is a competent manager who has successfully run the sister Home and is very aware of quality issues that need to be promoted within the Home and also that the provider needs to carry out Regulation 26 visits to the Home. Walcot Hall DS0000065021.V302425.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 X X 3 X X 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 2 2 X X 3 3 2 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 2 X X 2 3 3 Walcot Hall DS0000065021.V302425.R01.S.doc Version 5.2 Page 22 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 OP33 Regulation 26 Requirement The registered persons must ensure that visits on behalf of the registered provider are conducted as set out in regulations with copies of reports supplied to the Commission. The registered persons must establish and implement a system for monitoring and improving the quality of the service with copies of associated reports supplied to the Commission. The registered persons must establish and implement a system for supervising all staff in accordance with national minimum standards. Timescale for action 29/06/06 2. OP33 24 29/06/06 3. OP36 18(2) 29/06/06 Walcot Hall DS0000065021.V302425.R01.S.doc Version 5.2 Page 23 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 provide the Commission with a schedule of works identified as necessary for improving the premises, with anticipated timescales. The registered persons should arrange for an audit of all records required by regulations and schedules, to identify and address shortfalls and put risk assessments in place. It is recommended that the cleaning rosters in the kitchen are kept up to date. It is recommended that designated storage space be found for wheelchairs. 2. OP37 3. 4. OP37 OP19 Walcot Hall DS0000065021.V302425.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Walcot Hall DS0000065021.V302425.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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