CQC report explained · a residential care home
What the CQC found at Hethersett Hall
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Inspectors were assured that the home was using personal protective equipment, testing, hygiene, social distancing and other infection control measures safely.
- Effective?
- Requires improvement
- This question was not rated in this targeted inspection.
- Caring?
- Good
- This question was not rated in this targeted inspection.
- Responsive?
- Requires improvement
- This question was not rated in this targeted inspection.
- Well-led?
- Requires improvement
- This question was not rated in this targeted inspection.
What inspectors found, March 2022
Hethersett Hall was inspected but not rated; inspectors found good infection control arrangements during a COVID-19 outbreak.
This was an unannounced, targeted inspection on 7 February 2022. Inspectors checked infection prevention and control arrangements and asked about staffing pressures linked to COVID-19.
Inspectors found good practice. Staff teams were grouped to reduce infection risks, personal protective equipment was used correctly, and staff had infection control training and competency checks.
The home had arrangements for testing, safe admissions, visiting, hand hygiene, laundry, crockery and managing outbreaks. Inspectors said they were assured these infection control measures were in place.
The home was inspected but not rated. This report does not provide an overall quality rating or ratings for the other four questions.
Staff infection control training
Staff had infection control training and competency checks, and inspectors said this supported them to put their training into practice.
“Staff completed training and competency checks in relation to infection, prevention and control; this supported staff to implement their training into practice.” from the report
Protective equipment
Staff were observed using personal protective equipment correctly. Inspectors were assured that it was being used effectively and safely.
“Staff were observed to wear personal protective equipment correctly.” from the report
Managing infection risks
Staff teams were organised around specific areas, and the home had arrangements for used laundry, cutlery and crockery when people had COVID-19.
“The principles of cohorting staff teams to support specific areas of the home, to reduce the risk of the spread of infection were in place.” from the report
Safe visiting
Risk assessments supported visiting, including during the outbreak. Essential care givers were included in testing and had access to protective equipment.
“Risk assessments were in place, in consultation with people and their relatives, to support safe visiting arrangements, including during the outbreak.” from the report
Inspectors raised no specific concerns in this report.
- 01What measures were used to manage COVID-19-related staffing pressures, and did these affect people's care?
- 02How are staff teams currently organised to reduce the spread of infection?
- 03How are essential care givers and other visitors tested and supported with personal protective equipment?
- 04How do you support people living with dementia with hand hygiene?
- 05What arrangements are used for laundry, cutlery and crockery during an infection outbreak?
This was an unannounced targeted inspection of infection prevention and control practices, with questions about staffing pressures; it did not provide an overall rating or rate the other four questions. This explanation was written from the published report of 1 March 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, August 2019
Rated Requires Improvement; inspectors found kind care and good activities, but medicines, care records and oversight were not reliable enough.
Inspectors visited without notice on 8 and 9 July 2019. They spoke with people, relatives and staff, observed care, and checked care plans, medicines records, audits and other documents.
The home was caring, with kind staff, positive relationships and activities that people enjoyed. Staff were described as available, supportive and able to adapt how they communicated. People had access to healthcare, food and drinks, and the home was clean.
There were important weaknesses. Records and guidance about medicines, risks, people's capacity, daily care and end of life were not always complete or accurate. Inspectors found a breach of Regulation 12 because risks were not always adequately assessed and mitigated.
The overall rating was Requires Improvement. Safe, Effective, Responsive and Well-led were all Requires Improvement. Caring was Good. This was a decline from the previous inspection, when all areas were Good and Well-led was Outstanding.
Kind relationships
People and relatives spoke warmly about staff. Inspectors saw pleasant, kind and caring interactions.
“We saw pleasant, kind and caring interactions between people and staff.” from the report
Activities and interests
People could take part in varied group and one-to-one activities, trips and religious practice.
“Activities included a bridge club, a gardening club, yoga, arts and crafts and physical activities.” from the report
Staff support
Staff reported receiving training, supervision and help from managers. They said they worked well as a team.
“Staff worked well as a team, had good morale and were well supported by their management.” from the report
Communication and choice
Staff adapted their communication for people with different needs and supported people to make choices.
“Staff adapted their communication to meet individual's needs.” from the report
Staffing and cleanliness
People, relatives and staff said there were enough staff, and inspectors found the home clean with infection control training and protective equipment available.
“People, relatives and staff consistently told us there were enough staff to meet people's needs and they did not have to wait for assistance.” from the report
As-required medicines
seriousGuidance and records for some as-required medicines were incomplete. In one case, records showed medicine being given above the maximum dose stated in the care plan.
“The medicine was being administered above the maximum dosage stated on the care plan, daily.” from the report
Incomplete care records
needs fixingCare records did not always give staff accurate, current guidance about daily care, health risks, preferences and end-of-life wishes.
“People's care records were not always accurate, up to date and detailed with sufficient guidance for staff.” from the report
Mental capacity records
needs fixingSome mental capacity assessments and best-interest records were missing. DoLS information was also sometimes incorrect or incomplete.
“There were no records of mental capacity assessments or best interests' meetings for decisions made around the frequent use of PRN psychotropic medicines.” from the report
Quality checks
needs fixingThe home's audits had not identified some of the problems found by inspectors, including issues with medicines records.
“There were weekly and monthly medicines audits, however these had not identified some issues we found with the records.” from the report
Regulatory table finding
seriousThe report's regulation table said risks were not always adequately assessed and mitigated and described infection control practices as poor, although the detailed findings said the home was clean and had infection control checks.
“Risks to people were not always adequately assessed and mitigated. Infection control practices were poor.” from the report
- 01What changes have you made to the records and guidance for as-required medicines since the inspection?
- 02How do you now check that medicines are given for a recorded reason and within the prescribed maximum dose?
- 03How are mental capacity assessments and best-interest decisions recorded for medicines, bed rails and medical treatment?
- 04How do you make sure care plans accurately record oral care, pain, health risks, personal preferences and end-of-life wishes?
- 05What evidence can you show that your audits now identify and fix the problems raised in this report?
This was an unannounced inspection covering all five CQC questions and the overall rating, with detailed checks of six care plans, 16 medicines records and other records. This explanation was written from the published report of 8 August 2019 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Hethersett Hall
3 rated inspections over 4 years: the service has slipped, from Good to Requires improvement.
- March 2022Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- August 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- February 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Outstanding
- February 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2013
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- February 2011
Registered with the Care Quality Commission on 15 February 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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