Background to this inspection
Updated
1 March 2022
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.
As part of CQC’s response to care homes with outbreaks of COVID-19, we are conducting reviews to ensure that the Infection Prevention and Control (IPC) practice is safe and that services are compliant with IPC measures. This was a targeted inspection looking at the IPC practices the provider has in place. We also asked the provider about any staffing pressures the service was experiencing and whether this was having an impact on the service.
This inspection took place on 07 February 2022 and was unannounced.
Updated
1 March 2022
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 www.cqc.org.uk