Care Home: Halsey House

Annual service review Name of Service: Halsey House The quality rating for this care home is: The rating was made on: two star good service 0 2 0 3 2 0 0 9 A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection We do an annual service review when there has been no key inspection of the service in the last 12 months. It does not involve a visit to the service but is a summary of new information given to us, or collected by us, since the last key inspection or annual service review.   Has this annual service review changed our opinion of the service?   No You should read the last key inspection report for this service to get a full picture of how well outcomes for the people using the service are being met. The date by which we will do a key inspection: Name of inspector: Jane Craig Date of this annual service review: 2 6 0 2 2 0 1 0 Annual Service Review Page 1 of 6 Information about the service Address of service: 31 Norwich Road Cromer Norfolk NR27 0BA 01263512178 01263513630 smills@britishlegion.org.uk www.britishlegion.org.uk The Royal British Legion Telephone number: Fax number: Email address: Provider web address:   Name of registered provider(s): Name of registered manager (if applicable) Conditions of registration: Category(ies) : dementia old age, not falling within any other category physical disability Conditions of registration: The maximum number of service users who can be accommodated is: 89 The registered person may provide the following category of service only: Care home with nursing - Code N, to service users of the following gender: Either, whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category Code OP, Physical disability Code PD, Dementia Code DE Have there been any changes in the ownership, management or the Yes service’s registration details in the last 12 months? If yes, what have they been: Date of last key inspection: Date of last annual service review (if applicable): Brief description of the service Annual Service Review Page 2 of 6 Number of places (if applicable): Under 65 Over 65 16 0 1 0 89 0 Change of manager 0 2 0 3 2 0 0 9 The Royal British Legion is the leading charity safeguarding the welfare of those who have served in the Armed Forces, and their dependants. A major part of its work is to provide short and long term care for ex Service men and women and their dependents. Halsey House is one of the Legions seven nursing/residential care homes. Previously a school, the Home was opened by the Legion after the Second World War and now accommodates 74 people. It is set in delightful gardens and is a short walk from the centre of Cromer on the North Norfolk Coast. Halsey House comprises of an original house that has recently been refurbished, and a large extension. Most of the rooms are en suite and all rooms have access to a wide range of bathrooms and toilets. Lifting equipment is available when needed. The service caters for people who have nursing needs as well as those requiring personal care. There is 24 hour qualified nursing care, supported by the local medical practice. A licensed bar with pool table is enjoyed by people using the service and their guests, there is also a private chapel that is used for Sunday Services or for quiet contemplation. Information is sent out to anyone making enquiries about admission. Information about fees and extra charges is available from the manager. Annual Service Review Page 3 of 6 Service update since the last key inspection or annual service review: What did we do for this annual service review? We looked at all the information that we have received, or asked for, since the last key inspection, which was carried out on 2nd March 2009. This included: The annual quality assurance assessment (AQAA) that was sent to us by the service. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. Information we have about how the service has managed any complaints. What the service has told us about things that have happened in the service, these are called notifications and are a legal requirement. The previous key inspection and the results of any other visits that we have made to the service in the last 12 months. Discussion with the manager. What other people have told us about the service. What has this told us about the service? The acting manager sent us the annual quality assurance assessment (AQAA) when we asked for it. It was clear and gave us all the information we asked for. From this information we were able to make a judgement that the home continues to provide a good service. The AQAA gave examples of what the service does well and some of the ways they have improved over the last year. For example, as a result of listening to people who use the service there had been improvements in the range of social and recreational activities on offer. The acting manager had also introduced safer systems for managing medication, which was a requirement we made after our last inspection. The AQAA outlined a number of plans to further improve the quality of life of the people living at the home. These include changes to the catering facilities and landscaping the outdoor space so that people using the service have a pleasant area to view or sit in the summer. Five people who use the service completed our surveys, four had been assisted by a member of staff. Their responses to the questions we asked were positive. They told us they received the care and support they needed and they were usually satisfied with the meals and the level of activities. When asked to comment on what the service does well, one person wrote, I think they all do well. None had any suggestions for how the service could be improved. Four staff also returned surveys. Their responses indicated that staff were recruited safely and received a good level of induction and ongoing training. One commented, There is an excellent training programme for all staff. Another wrote that standards were high and people received excellent care. However, their responses were not as positive about methods of communication in the home and support from their line manager. We discussed the staff surveys with the acting manager. She was aware that staff supervision had not been carried out as regularly as it should have been and has already taken steps to address this. The acting manager also told us that she would Annual Service Review Page 4 of 6 look into the comments about communication. Following our random inspection of 20th August 2009, we made a requirement that the staffing levels must be reviewed to ensure there were always enough staff on duty. Staff who completed surveys indicated that there were only sometimes enough staff to meet the individual needs of people using the service. We discussed this with the acting manager, who told us that staffing numbers were calculated according to the needs and dependencies of the people using the service. She was confident that there were always sufficient staff on duty. She had recently recruited a general assistant to help with non-direct care tasks such as catering, which should help to ensure care staff have more time to spend with residents. We will continue to monitor staffing levels in the home. People who returned surveys said they had someone to speak to if they were not happy about anything and staff indicated that they knew what to do if anyone raised concerns to them. According to the AQAA the home had received two complaints since the last inspection. They had been investigated within the specified time frame and had not been upheld. There had been no safeguarding referrals. The service had made an application to increase the number of places in the home and to change the registration to enable Halsey House to provide a service to people with dementia. The Commission was processing the application at the time of this review. The acting manager continues to work with us and sends in important information. From all the information we have received we have concluded that the service continues to provide good outcomes for the people who use it. What are we going to do as a result of this annual service review? Under the Care Quality Commission current inspection frequencies we must carry out a key inspection within three years of the last key inspection. However, we can inspect the service at any time if we have concerns about the quality of the service or the safety of the people using the service. Annual Service Review Page 5 of 6 Reader Information Document Purpose: Author: Audience: Further copies from: Annual service review CQC General Public 0870 240 7535 (national contact centre) Our duty to regulate social care services is set out in the Care Standards Act 2000. The content of which can be found on our website. Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a copy of the findings in a different format or language please contact our helpline or go to our website. © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. 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