Care Home: Hethersett Hall

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What the care home does well A beautiful location in a beautiful building created pleasant initial conditions for residents. An old manor building with preserved original features and modern added extensions remained an attractive place to live. Regular and well managed maintenance ensured that the environment was appropriate for residents. Division in the home to the Main Wing and the Garden Wing allowed the home to respond more appropriately to the common needs of the particular resident group, accommodating residents with dementia together in the Garden Wing. The home had recently gone through big changes. Not only the new manager, but also big staff turnover obviously affected the home’s daily routine. Several months after the changes took place, the home was stabilising and running in a consistent way, offering good care and protecting residents. Increased the staffing number in Garden House ensured appropriate care for residents with dementia, where staff did have time to focus on individuals and allocate time to simply talk to residents in addition to offering day to day care. Respect for residents’ ability to remain as independent as possible was emphasised. Residents’ privacy and dignity were respected. They could hold their bedroom keys, their post was given to them unopened and they were generally treated with full respect.Hethersett HallDS0000048257.V378331.R01.S.docVersion 5.2The home used only one agency to cover for staff absences, thus preserving continuity of care. Change of format for care plans and other records was just completed improving person centred principles of care. Staff training was recently reorganised and the new matrix ensured that all staff received regular training. What has improved since the last inspection? The home responded appropriately to the requirements set on previous inspections. Care plans in the dementia wing were reviewed and improved. Now, the home consulted a GP too when residents’ last wishes were recorded, thus ensuring appropriate decisions were confirmed by the professionals as well. Evacuation bags were created to ensure that in case of evacuation basic details and basic necessities were ready for each individual. Keeping information in one place was improved when previously used communication books were taken away and the process of recording messages in a diary was introduced. This reduced scattering information and ensured better control of information. Naming the persons responsible for Health and Safety in each wing improved the outcomes and protection of residents. Risk assessments were improved and the MUST tool to monitor nutrition was introduced. Residents spoken to indicated that staff response to their needs and calls had improved and waiting times had been reduced. The majority of residents had already been spoken to and consulted about their care plans and the manager stated that relatives were getting more involved in the planning process. The manager stated that she had reviewed the plans since the random inspection to organise faster and better staff response to residents needs. Residents spoken to confirmed that waiting time was reduced. The manager also admitted some reactions from and resentment of staff to the new working principles, but that most issues had been resolved and the remaining reactive thinking was addressed to ensure consistency and effectiveness of the whole staff team. The staff turnover was recently reduced, following on from the huge turnover at the time of the change of the manager. What the care home could do better: Although the new care plan format better suited staff to identify their tasks related to each individual, small discrepancies still needed to be corrected on the forthcoming reviews, to ensure that all information was transferred correctly and addressed when necessary in new residents’ documentation. ThisHethersett HallDS0000048257.V378331.R01.S.doc Version 5.2 would ensure that all staff work with the same effectiveness with every individual in the home. The home would still need to improve the staff atmosphere and collectiveness which would create a positive, motivating and satisfactory atmosphere throughout the home and for the staff team. Key inspection report CARE HOMES FOR OLDER PEOPLE Hethersett Hall Hethersett Norwich NR9 3AP Lead Inspector Dragan Cvejic Key Unannounced Inspection 5th November 2009 09:20 DS0000048257.V378331.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Hethersett Hall DS0000048257.V378331.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Hethersett Hall DS0000048257.V378331.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hethersett Hall Address Hethersett Norwich NR9 3AP 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) 01603 810478 01603 810860 hethersett@barchester.com www.barchester.com Barchester Healthcare Homes Ltd Manager under the process of registration Care Home 70 Category(ies) of Dementia - over 65 years of age (50), Old age, registration, with number not falling within any other category (20) of places Hethersett Hall DS0000048257.V378331.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th February 2009 Brief Description of the Service: Hethersett Hall comprises of a late regency manor house with 3 modern extensions. The home has two units; the Main Hall which consists of two storeys provides residential accommodation for older people and the Garden House, which provides residential accommodation for older people with dementia. Hethersett Hall’s accommodation consists of 44 single and 2 double bedrooms with en-suite facilities in the Main Hall, and the Garden House accommodation consists of 21 single with en-suite facilities. The Home is owned by Barchester Healthcare Ltd. Hethersett Hall is situated on the outskirts of the village of Hethersett, approximately two miles from the A11. The range of fees is published in the initial documentation obtainable from the home. Hethersett Hall DS0000048257.V378331.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This was an unannounced inspection of the service. The service was reviewed through an annual service review on 12/10/09 and was inspected through a random inspection on 28/09/09, after a number of concerns were expressed by ex members of staff. Findings from these activities are incorporated into this report. This inspection included a site visit, carried out on 05/10/09, when two inspectors visited the home and checked all key standards through outcome based principles. The inspectors talked to a number of residents, to staff members, to the management of the home and to 2 senior managers from the organisation who visited the home at the same time. A number of residents and staff files were checked, as well as the AQAA, an Annual Quality Assurance Assessment carried out by the home and submitted as a part of the regulatory process. What the service does well: A beautiful location in a beautiful building created pleasant initial conditions for residents. An old manor building with preserved original features and modern added extensions remained an attractive place to live. Regular and well managed maintenance ensured that the environment was appropriate for residents. Division in the home to the Main Wing and the Garden Wing allowed the home to respond more appropriately to the common needs of the particular resident group, accommodating residents with dementia together in the Garden Wing. The home had recently gone through big changes. Not only the new manager, but also big staff turnover obviously affected the home’s daily routine. Several months after the changes took place, the home was stabilising and running in a consistent way, offering good care and protecting residents. Increased the staffing number in Garden House ensured appropriate care for residents with dementia, where staff did have time to focus on individuals and allocate time to simply talk to residents in addition to offering day to day care. Respect for residents’ ability to remain as independent as possible was emphasised. Residents’ privacy and dignity were respected. They could hold their bedroom keys, their post was given to them unopened and they were generally treated with full respect. Hethersett Hall DS0000048257.V378331.R01.S.doc Version 5.2 Page 6 The home used only one agency to cover for staff absences, thus preserving continuity of care. Change of format for care plans and other records was just completed improving person centred principles of care. Staff training was recently reorganised and the new matrix ensured that all staff received regular training. What has improved since the last inspection? What they could do better: Although the new care plan format better suited staff to identify their tasks related to each individual, small discrepancies still needed to be corrected on the forthcoming reviews, to ensure that all information was transferred correctly and addressed when necessary in new residents’ documentation. This Hethersett Hall DS0000048257.V378331.R01.S.doc Version 5.2 Page 7 would ensure that all staff work with the same effectiveness with every individual in the home. The home would still need to improve the staff atmosphere and collectiveness which would create a positive, motivating and satisfactory atmosphere throughout the home and for the staff team. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Hethersett Hall DS0000048257.V378331.R01.S.doc Version 5.3 Page 8 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 Hethersett Hall DS0000048257.V378331.R01.S.doc Version 5.3 Page 9 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,4,5 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective residents and their relatives could choose the home based on information provided prior to admission and on properly conducted initial assessments as an indicator that the assessed needs would be met. EVIDENCE: At the reception area there was a set of documents about the home, including a certificate of registration, insurance certificate, the statement of purpose and the service users’ guide. In their AQAA, a self assessment, the manager stated: “A comprehensive brochure and internet site is also available. Enquirers are also given details as to gain information about the home from inspection reports via CQC.” The admission process was explained by the manager and checked in Hethersett Hall DS0000048257.V378331.R01.S.doc Version 5.3 Page 10 residents’ files. The AQAA also addressed the admission and stated: “Prospective residents are offered visits to the home to be shown around and to join us for refreshments, they are also invited to visit us unannounced, further information is available about funding arrangements and advocacy services. Prospective residents are then given a detailed pre admission assessment to ensure that the home is able to meet their health and social care needs. Following this assessment it is confirmed to the prospective resident whether a suitable placement can be met.” Residents files were checked both in the dementia and the main wing and all contained details of pre-admission and assessment on admission. Hethersett Hall DS0000048257.V378331.R01.S.doc Version 5.3 Page 11 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents benefited from an individualised approach to their care, from good staff knowledge of their needs and from the respect shown to their abilities to remain as independent as possible. EVIDENCE: Checked files both in dementia unit and in the main wing demonstrated that detailed and person centred care plans were developed to help staff meet the assessed needs of residents. This new format appropriately addressed the needs and the actions to be taken to meet those. One of the checked transferred files did not contain an appropriate entry for a resident who wears glasses but contained an entry stating simply “good sight”. However, these minor discrepancies could be easily addressed and corrected when the full care plan review is conducted. Hethersett Hall DS0000048257.V378331.R01.S.doc Version 5.3 Page 12 Several residents commented that they were “happy with care plans”. One of them stated: “I am not very interested in care plan, as I am pretty independent, but they ask me for my opinion on reviews.” Inside checked care plans there were elements of evidence of good healthcare practices. One of the checked files contained the entry: “Does not always agree to shaving daily”, explaining why the resident was not shaven when he spoke to us. The other file stated: “to see chiropodist every 6 weeks.” The section where external professionals visited individuals showed that regular chiropody visits were recorded. Care plans and risk assessments were regularly reviewed and “evaluations”, as the home called these reviews, were appropriate. Medication process and records were checked. The sampled records did not show any gaps and were in order. A resident who self medicated inhalers had a risk assessment for that in place. Staff who were administering medication were trained and the last training session happened a day before the site visit and was organised by Boots, who were supplying prescribed medication for residents. Controlled drugs were appropriately stored and the records were accurate. The amount of medication was checked for two residents and corresponded to the records. The AQAA stated: “Medication administration is audited weekly.” Residents’ privacy and dignity were respected. A resident explained to us that he was getting his newspapers delivered every morning. The home in addition produced a set of free local newspapers. The minutes of the residents’ meeting showed that they asked a particular member of staff to “analyse” and read newspapers with them. Staff were observed knocking on the door before entering a resident’s room in the dementia unit. The home recorded residents’ last wishes in consultation with them, with their relatives and with their GP. Hethersett Hall DS0000048257.V378331.R01.S.doc Version 5.3 Page 13 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Activities within the home were appropriate and the issues regarding kitchen and food also showed good outcomes for residents within this group of standards. EVIDENCE: The AQAA, a self assessment reported: “The individual needs of each resident with regards to how they choose to manage their day is detailed throughout the care plan. In particular the activity information section which details the residents’ preference of socialisation, a wide range of activities is available and family and friends are offered the chance to attend.” The files checked contained comprehensive records of life history which included details of residents’ likes, dislikes and preferences and helped staff meet these assessed needs. The home organised a variety of social activities to keep residents motivated and engaged. Environmental elements also helped the home stimulate residents’ memory, Hethersett Hall DS0000048257.V378331.R01.S.doc Version 5.3 Page 14 both with displayed old pictures and features throughout the home and by allowing residents to bring their personal possessions into their rooms. Residents’ autonomy was promoted in the home. Thus, one of the residents stated: “I look after my own money and finances. I don’t need them (staff) to help me with that.” Even during the site visits, there were several visitors visiting individuals and their right to privacy was fully respected. The home reported in their AQAA: “Our chef prepares fresh home cooked food on a daily basis and a number of choices are available at each meal time. A wide range of dietary needs can be met at all meals and are served with a selection of drinks.” Speaking to residents in the dining room during the lunch, all 7 confirmed that the food was good and to their liking. The nutritional tool, MUST, in residents’ files was used to record nutritional aspects of care for residents. Hethersett Hall DS0000048257.V378331.R01.S.doc Version 5.3 Page 15 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Clearly displayed and appropriately followed complaints procedure reassured residents that they could complain with confidence and that they were protected by the appropriate safeguarding measures being in place. EVIDENCE: There were a number of complaints at the time of the change of manager. Although some complaints addressed the new management style as being authoritarian, some addressed issues such as the staffing level and atmosphere in the home that triggered a random inspection. That inspection was presented in a random report and resulted in additional requirements. These requirements were met by the time of this site visit and inspection. Some of these complaints and concerns were redirected to the organisation for investigation. All referred concerns were appropriately investigated and responded to within the time scale, showing that the organisation and the home acted appropriately and took complaints seriously. The procedure was displayed throughout the home and was made available. The home reported that they had received 2 complaints and investigated them according to the complaints procedure. There were no allegations of events that were referred to safeguarding authorities and the company used their own disciplinary procedure to address Hethersett Hall DS0000048257.V378331.R01.S.doc Version 5.3 Page 16 staffing issues, except issues surrounding the home’s previous manager. The dismissal of the previous manager was done in consultation and cooperatively with external authorities and in the best interest of, and for the protection of residents. Three staff members spoken to confirmed that they were aware of the whistle blowing procedure. In addition, the home reported in their AQAA: “All staff receive training in the safety of vulnerable adults. All staff are aware of the whistle blowing policy.” Hethersett Hall DS0000048257.V378331.R01.S.doc Version 5.3 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A nice and pleasant environment appropriately divided into units helped residents feel relaxed and at home. Infection control measures were in place. EVIDENCE: The tour of the home and reported state of the home in the AQAA indicated that the home was appropriate for the assessed residents’ needs. The manager was aware of just one bath to 16 residents in one wing in the main building and was looking into a potential solution to ensure that all residents in that wing would still be able to receive described care. The building of a new summer house was in progress, resulting from the residents’ comments during their meetings. Hethersett Hall DS0000048257.V378331.R01.S.doc Version 5.3 Page 18 The home reported in their AQAA: “We offer a safe, comfortable and homely environment for all residents which is well maintained, safe and hazard free. Our housekeeping team work to keep all areas of the home clean, free from odours and a hygienic place in which to live. We have a system and policies in place to control the spread of infection. We meet regularly with our property support team, including building maintenance and interior design to ensure that the home maintains a safe, modern environment able to meet the needs of the residents. We regularly carry out redecoration in areas of the home when required and all bedrooms are deep cleaned and redecorated (where necessary) before a new resident moves in.” Residents spoken to confirmed that they were happy with the environment the home offered. A cleaner spoken to, stated: “We manage to keep the home clean.” Two laundry assistants admitted that washing machines were working “around the clock”, but also confirmed that they managed their workload to the satisfaction of residents. Hethersett Hall DS0000048257.V378331.R01.S.doc Version 5.3 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in the home are satisfied with the care they receive, that it meets their needs, delivered by a trained staff team. EVIDENCE: A random inspection carried out earlier confirmed pre-employment checks for staff were carried out appropriately. It also identified some discrepancies of staff on the shift and on the rota. However, this key inspection demonstrated that staff were engaged to work as planned, ensuring a sufficient number of staff were on duty. The staffing atmosphere had also improved since the random inspection, minimising the number of staff who were reluctant to accept new working procedures. Three staff spoken to confirmed that a better atmosphere had started emerging in the home. The dementia unit was observed by two inspectors and both recorded that staff were spending time with residents and allocated individual time to those that needed closer supervision. Although the part of the main hall accommodating less dependent residents was staffed by 3 staff for 21 residents, their independence allowed staff to meet their needs. In addition several residents spoken to stated: “If I need help, I just press buzzer and someone is there” and “Staff are kind”. Hethersett Hall DS0000048257.V378331.R01.S.doc Version 5.3 Page 20 One of the newly admitted residents commented: “I was so worried until I came here and now I am less scared as there is always someone here to help.” The manager explained that “hosts”, a new staff category, staff that serve tea and coffee and spend time with residents and visitors steps in when necessary to help with other tasks. One of these staff members was seen helping a resident to eat. The home’s AQAA stated: “Residents needs are met by the number and skill mix of staff which are dictated by the total care assessments carried out for all residents, staffing skills and generics of the building. All new staff are recruited appropriately to ensure the continued safety of residents. Staff receive a thorough induction in accordance with skill for care and Barcester induction policies and protocol. Staff receive training in all key areas of care.” The AQAA reported that 22 workers held NVQ qualifications, and the manager added that, at the time of site visit the percentage was around 50 of staff who held this qualification. New, improved training was available to staff, when the company employed new trainers. One of the staff who worked as a carer originally returned to work in the home as a trainer after spending two years away and while gaining necessary trainer’s skills. She had just introduced a new training matrix to closely monitor and address training needs. Hethersett Hall DS0000048257.V378331.R01.S.doc Version 5.3 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home ensured residents were well protected by safe working practices that were constantly monitored. The atmosphere was improving following a high staff turnover which had affected both the staff team and residents. EVIDENCE: The manager came here from her previous position as a registered manager in another home, bringing her skills, experience and knowledge. She implemented strict guidelines for staff on how to work, as part of the changed processes and procedures. Hethersett Hall DS0000048257.V378331.R01.S.doc Version 5.3 Page 22 A huge staff turnover, whereby about 30 new staff were employed in just a few months, had affected the atmosphere in the home, but by the time of the site visit, the atmosphere had started to stabilise, residents were less affected and the manager stated that in a short time the home would be settled. Quality assurance was conducted at the organisational level. The manager in addition held residents and relatives’ meetings approximately once a month, until recently when the time scale reduced meetings to quarterly. The home also published their own newsletter, as was seen on display in the main reception area. The manager also invited relatives a few days prior to the meeting, in case they were not able to attend, to provide their comments. The home in general did not deal with residents’ finances and called social workers and relatives to help in this area. The AQAA reported: “Monthly internal audits are undertaken as directed by the Director of Quality of Care. In addition to this a monthly visit is carried out under regulation 26. The audits ensure that a Barchester home provides effective quality assurance procedures and assists the home in meeting the aims and objectives, ensuring good outcomes for residents. Effective management of financial procedures are adopted to ensure financial viability. Public liability insurance cover is in place and displayed within the entrance area of the home. Care staff receive supervision 6 times a year part of the supervision is to discuss any training and development needs. The home has a full time maintenance person who is responsible for all aspects of Health and Safety both internally and externally. The organisation employs and external body to carry Health and Safety inspections of the home.” There were no reported incidents related to infection control and the procedure to ensure health and safety were in place. Hethersett Hall DS0000048257.V378331.R01.S.doc Version 5.3 Page 23 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 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 4 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 2 3 X 3 3 X 3 Hethersett Hall DS0000048257.V378331.R01.S.doc Version 5.3 Page 24 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 OP7 Good Practice Recommendations Residents’ files should contain consistent information throughout, including addressing glasses in care plan and the assessment of residents’ eyesight in the activities section. Hethersett Hall DS0000048257.V378331.R01.S.doc Version 5.3 Page 25 Care Quality Commission Eastern Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.eastern@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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