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Hethersett Hall Requires improvement


Inspection carried out on 8 July 2019

During a routine inspection

About the service: Hethersett Hall provides accommodation and support to a maximum of 70 older people, some living with dementia. It does not provide nursing care.

People’s experience of using this service:

Medicines were stored safely, but records for ‘as required’ (PRN) medicines were not always in place to show they were given appropriately. We have made a recommendation about this.

People’s care records were not always accurate, up to date and detailed with sufficient guidance for staff. This included records around people’s daily care, mental capacity and end of life. We have made a recommendation about following the Mental Capacity Act (MCA).

Not all risks to people’s health were fully covered in their care plans, however risks to people’s environment were mitigated.

Care plans were not always detailed with individual preferences and sufficient guidance for staff.

There were some effective quality assurance systems in place, but not all areas for improvement had been identified.

People had a range of activities which they engaged in and enjoyed, and they had positive relationships with staff.

Staff adapted their communication to interact with people in a way they understood.

Staff worked well as a team and were supported with training and supervision by a good leadership team.

People had access to healthcare and were supported to follow a healthy balanced diet and enough to drink.

Rating at last inspection: Good in all areas with outstanding in well-led (Published February 2017)

Why we inspected: We inspected this service in line with our schedule for services rated Good.

Follow up: We will continue to monitor the service according to our schedule for returning to locations rated Requires improvement.

For more details, please see the full report which is on the CQC website at

Inspection carried out on 9 January 2017

During a routine inspection

The inspection took place on 9 January 2017 and was unannounced. The service provided accommodation for up to 70 people who require nursing or personal care. There were 60 people living in the home when we inspected, some living with dementia.

A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. There was a registered manager who had been in post since June 2015.

The home was safe, and staff had relevant training in keeping people safe from harm. The environment was kept safe and risks relating to individuals were thoroughly assessed and mitigated. Staff safely supported people to take their medicines, and there were enough staff to meet people’s needs. Staff were recruited in a safe way.

People received care from well-trained staff who were confident and competent in their roles. The organisation supported staff to undergo training and supervisions to improve their practice. Staff knew about people’s capacity to make decisions and had received relevant training in this area.

People had a wide choice of what to eat and drink and staff supported people to have their meals in a way that suited them. People were supported to eat and drink enough. Staff sought consent from people when delivering care, and adapted their communication effectively with people, empowering them to make choices.

Staff were compassionate and kind towards people and there was a good atmosphere in the home. People were supported to follow their interests, enjoy visiting entertainment and go out when they had the opportunity.

People had records in place relating to their care, and these were tailored to each person. Where appropriate, family members were consulted about people’s care along with the person and staff. The care records contained specific guidance for staff on people’s support needs, and staff knew people well.

There were effective systems in place for gaining feedback from people, and concerns or complaints were responded to appropriately, sensitively, and in a timely manner. People were encouraged to give feedback both to individual members of staff as well as in meetings, and the registered manager was proactive in making improvements based on feedback.

There were thorough auditing systems in place to monitor, analyse and improve the service provided. Where incidents and accidents had occurred, these were analysed in an innovative way and used as learning opportunities for improvement.

There was a positive, open and honest relationship between staff and the registered manager in the home, and any errors were used for learning.

Staff worked very well as a team, sharing values of delivering high quality care, and they were extremely complimentary about the registered manager. There was high staff morale and they took pride in their roles. The home had a strong presence within the local community, maintaining links and hosting various events for the community throughout the year

Inspection carried out on 28 October 2014

During a routine inspection

This inspection took place on 28 October 2014 and was unannounced.

Hethersett Hall is a residential care home that provides accommodation, care and support for up to 70 older people, some of who are living with dementia. At the time of the inspection, there were 55 people living at Hethersett Hall, 27 of which were living in a dementia unit named Memory Lane. There was a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

All of the people we spoke with told us they felt safe living at the home and that their needs were met by staff who were caring, respectful and friendly. Staff treated people with respect and used a kind and considerate approach when talking with and assisting them. People told us they found the staff and manager approachable and could speak to them if they were concerned about anything.

Staff knew how to make sure that people were safe and protected from abuse. They had been trained and had the skills and knowledge they needed to provide support to the people they cared for. They had completed training in the Mental Capacity Act (2005) and understood when best interest decisions were needed and an application was required to be sent to a local authority Supervisory Body.

People had access to healthcare professionals when they became unwell or required specialist help with a medical condition. Their independence was encouraged. People and/or their relative were consulted and involved in reviewing their plans of care to ensure their needs were met.

The staff were happy working at the home and told us that the management team were supportive, that they listened to them and that changes in care practice were implemented when concerns had been raised. A survey questionnaire had been sent to people to gain their view of the care and support provided. People told us their concerns and complaints were quickly dealt with and resolved to their satisfaction.

Regular checks were made on the way staff worked, the records held and the premises to make sure the home was well run and people received the care and support they needed. Medicines were stored correctly and records showed that people had received them as prescribed.

Inspection carried out on 11 June 2013

During a routine inspection

People told us that they liked living at Hethersett Hall. One person said, "I doubt there is a better place than this". Another person spoke about being able to spend their time wherever they wished. We were told that staff were kind and attentive. People told us they felt able to make choices about all aspects of their daily living. Staff described how they understood and knew about the history and care needs of people living with dementia so that they could act in their best interests.

We looked at care plans and saw that they provided information to staff so that they could provide appropriate care and support. Staffing levels were sufficient for staff to meet people's needs without the need to rush people. We saw that senior staff were qualified and experienced enough to provide advice and guidance to carers where necessary. Sufficient ancillary staff were employed to allow care staff to concentrate on providing care and support.

The home was well maintained inside and out, with a good standard of decoration throughout. All areas were clean and tidy and free of unpleasant odours. Maintenance plans were in place so that the potential risk of breakdowns was reduced.

The service had a complaints process in place that was clearly displayed in the home. We saw that the service took all expressions of concern or complaint seriously and that any complaints that could not be resolved locally were escalated to senior managers to deal with.

Inspection carried out on 3 August 2012

During a routine inspection

As part of this inspection we used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us. We chose to use SOFI in the dining room and lounge of the Garden House because this was where people with more complex needs were spending their time. We observed the people in the lounge for 20 minutes and the dining room for 20 minutes noting the experiences of four people. We saw that staff treated people with dignity and respect when providing support with eating and drinking and that each person was given individual attention and support. No one was hurried and throughout the time people were constantly offered choices. �Which drink would you prefer, orange or lemon.� �Would you like your meal at the table or sitting in the armchair,� �Would you like to dance to the music or just listen.� All conversations were offered at eye level and the staff members made sure they were understood by offering the person time to give their answer.

People told us they felt safe in the home and that staff were always kind, courteous and respectful.

They told us there was always plenty to do and that they could always choose how they wished to spend their day. They gave us varied examples of how they kept themselves busy and how they enjoyed each others company.

Inspection carried out on 19 October 2011

During a routine inspection

People with whom we spoke told us that they felt that Hethersett Hall was a very nice place to live in and one of them stated: �Lovely place, lovely people, lovely staff.�

Everyone was very complimentary regarding the staff and stated that staff were excellent. People felt that staff were well trained and explained, �They knew their job�.

People told us that they felt safe and protected in Hethersett Hall. One person told us that they lived in many countries but felt the safest in this home, in this broader area where Hethersett Hall was located and in England. Another person proudly stated that that they had lived locally all their life and were especially pleased when a place in Hethersett Hall became available and they moved in.

People stated that they could see a doctor or a nurse or any other health professional if they needed to. One person explained that they knew when the nurse was coming to redress their legs.

People knew about their medication and were happy for staff to look after it. A person with whom we spoke stated that they knew all their medication.

People felt that they not only had choices, but also that they could voice their feelings through regular meetings, through �The open door policy� and through direct contact with any staff member, as they explained: �I can call a maintenance man, or tell staff, or tell the manager if I need anything.�

Reports under our old system of regulation (including those from before CQC was created)