Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 11/09/07 for Hatzfeld House Care Home.

Also see our care home review for Hatzfeld House Care Home. for more information

This inspection was carried out on 11th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Care plans viewed provided an overview of individual service users needs. Service users healthcare needs are generally well met. The service users and relative spoken with reported that they were happy with the services provided and that they felt their needs were met fully. Service users were observed be relaxed and appeared contented with the routines of the home.Staff, were observed to speak to service users respectfully and inform them when they needed to be moved/transferred etc and service users likes/dislikes and choices are respected. Service users presented well cared for and appropriately dressed. Service users and a relative spoken with were happy with the services provided and said that their privacy and dignity was respected. Service user comments included the following Statements " Staff are kindness" and "the staff are excellent". They reported that they were happy with the food and the activities provision and that they felt confident to make complaints. Service users benefit from a comfortable, appropriately furnished and well decorated environment, which provides specialist equipment, suitable lavatories and washing facilities and bedroom space to suit their needs and maximise their independence. The home was observed to be, on the whole, well maintained and kept clean and fresh smelling. The manager is qualified and has the necessary experience to run the home. Staff service users and relatives spoke highly of the manager and her approachability. The views of service users are obtained about the quality of the service.

What has improved since the last inspection?

The service now has an up to date Statement of Purpose, which sets out the aims and objectives of the home, and includes a service user guide, which provides basic information about the service and the specialist care the home offers. The guide is now made available to individual service users who are being asked to sign they have received a copy. Recruitment procedures have been improved. The provider has undertaken a review of the staffing levels since the last inspection and the manager works full time super-numery in respect of her responsibilities. Sufficient catering hours domestic and laundry are now provided. Food safety practices have been improved. Screening tools have been introduced to identify where service users may be at risk of pressure areas. All staff have been issued with a copy of the General Social Care Councils Code of Conduct Booklet.

What the care home could do better:

Provide more evidence to show that service users financial systems are protected by the home Records must be available for inspection at all times. Ensure medication systems always follow good practice or safe practice guidelines. Improved record keeping for meal taken by service users. Make good the enamel on the base of the bath hoist. Ensure the broken tiles in the extension bathroom are repaired. Provide staff with training in: Diabetes Care, Mental Health difficulties and for Catheter Care. Five requirements are set in respect of the above and twelve good practice recommendations have also been made.

CARE HOMES FOR OLDER PEOPLE Hatzfeld House Care Home 10b Mansfield Road Blidworth Nottinghamshire NG21 0PN Lead Inspector Jayne Hilton Unannounced Inspection 11th September 2007 11:10 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Hatzfeld House Care Home DS0000028615.V349253.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Hatzfeld House Care Home DS0000028615.V349253.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hatzfeld House Care Home Address 10b Mansfield Road Blidworth Nottinghamshire NG21 0PN 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) 01623 464541 01623 465508 hatzfeldcareltd@btconnect.com Mr Roger Willis Tracey Julia Graham Care Home 23 Category(ies) of Dementia (23), Old age, not falling within any registration, with number other category (23) of places Hatzfeld House Care Home DS0000028615.V349253.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only:Care home only - Code PC To the 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 Dementia - Code DE The maximum number of service users who can be accommodated is: 23 4th April 2007 2. Date of last inspection Brief Description of the Service: Hatzfeld House is a converted property, set in its own grounds in the centre of Blidworth. It is within walking distance of all the local amenities and on a public bus route. Service users are accommodated in one double and twenty-one single bedrooms with a communal lounge, dining room and conservatory. Disability equipment in the home includes a passenger lift, ramped access to the building, grab rails in bathrooms/toilets, handrails in corridors, mobile/bath hoists and raised toilet seats. A call system is available in all the rooms, including communal living space. The Service User Guide includes terms and conditions of residency but does not detail the range of fees charged. The manager reported on 11/9/07 that the range of Weekly fees are between£290 - £390 Service users pay extra for personal newspapers, hairdressing and chiropody, physiotherapy and any special dietary arrangements. A copy of the inspection report on the home is available in the reception. Hatzfeld House Care Home DS0000028615.V349253.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection is upon outcomes for service users and their views on the service provided. This process considers the provider’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. This inspection took place over 5 daytime hours. The main method of inspection used was called ‘case tracking.’ This involves selecting two residents and looking at the quality of the care they receive by talking to them, examining their care files and discussing how support is offered to them by staff members. Not all of the residents who were “case tracked” were able to help by giving an opinion about the care provided, however three residents and one relative were spoken with during the inspection visit. Two members of staff and the manager were spoken with as part of this inspection, documents were read and medication inspected to form an opinion about the quality of the care provided to residents. A partial tour of the environment was also facilitated. The annual quality assurance assessment completed by the registered provider was not unfortunately received before the writing of this inspection report. No service user surveys were returned to the Commission for Social Care Inspection. What the service does well: Care plans viewed provided an overview of individual service users needs. Service users healthcare needs are generally well met. The service users and relative spoken with reported that they were happy with the services provided and that they felt their needs were met fully. Service users were observed be relaxed and appeared contented with the routines of the home. Hatzfeld House Care Home DS0000028615.V349253.R01.S.doc Version 5.2 Page 6 Staff, were observed to speak to service users respectfully and inform them when they needed to be moved/transferred etc and service users likes/dislikes and choices are respected. Service users presented well cared for and appropriately dressed. Service users and a relative spoken with were happy with the services provided and said that their privacy and dignity was respected. Service user comments included the following Statements “ Staff are kindness” and “the staff are excellent”. They reported that they were happy with the food and the activities provision and that they felt confident to make complaints. Service users benefit from a comfortable, appropriately furnished and well decorated environment, which provides specialist equipment, suitable lavatories and washing facilities and bedroom space to suit their needs and maximise their independence. The home was observed to be, on the whole, well maintained and kept clean and fresh smelling. The manager is qualified and has the necessary experience to run the home. Staff service users and relatives spoke highly of the manager and her approachability. The views of service users are obtained about the quality of the service. What has improved since the last inspection? The service now has an up to date Statement of Purpose, which sets out the aims and objectives of the home, and includes a service user guide, which provides basic information about the service and the specialist care the home offers. The guide is now made available to individual service users who are being asked to sign they have received a copy. Recruitment procedures have been improved. The provider has undertaken a review of the staffing levels since the last inspection and the manager works full time super-numery in respect of her responsibilities. Hatzfeld House Care Home DS0000028615.V349253.R01.S.doc Version 5.2 Page 7 Sufficient catering hours domestic and laundry are now provided. Food safety practices have been improved. Screening tools have been introduced to identify where service users may be at risk of pressure areas. All staff have been issued with a copy of the General Social Care Councils Code of Conduct Booklet. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can Hatzfeld House Care Home DS0000028615.V349253.R01.S.doc Version 5.2 Page 8 be made available in other formats on request. Hatzfeld House Care Home DS0000028615.V349253.R01.S.doc Version 5.2 Page 9 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 Hatzfeld House Care Home DS0000028615.V349253.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have the information they need to make an informed choice about where they live. The process for assessment, review and evaluation of changing needs of service users needs minor amendment/additions to ensure all service users needs are fully met. An intermediate care service is not provided by this home. EVIDENCE: Service users needs are assessed before they move to the home, however the cultural and diversity needs of individuals should also be expanded upon within the documentation. Hatzfeld House Care Home DS0000028615.V349253.R01.S.doc Version 5.2 Page 11 Contracts are available and the manager had confirmed to the service users that then home could meet their needs prior to their admission. The home has recently been registered to provide a service for people with Dementia. The service users and relative spoken with reported that they were happy with the services provided and that they felt their needs were met fully. Service users were observed be relaxed and appeared contented with the routines of the home. Staff, were observed to speak to service users respectfully and inform them when they needed to be moved/transferred etc. Care plans were noted to identify likes and dislikes and preferences. Service users confirmed these choices were respected. Service users were dressed appropriately and confirmed staff promotes their independence. The service has developed an up to date Statement of Purpose, which sets out the aims and objectives of the home, and includes a service user guide, which provides basic information about the service and the specialist care the home offers. Service users are now issued with their own copy. There is a copy of the inspection report displayed in the entrance and the service users guide informs the reader how they can access a copy of the report from the home. It is recommended that information be expanded to inform individuals of how they can access inspection reports on the Internet also. Hatzfeld House Care Home DS0000028615.V349253.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users privacy and dignity is respected and their health, personal and social needs are generally set out in a plan of care, however the systems in place for monitoring and evaluating the healthcare needs of service users need to be improved to ensure that risks are appropriately assessed and minimised. EVIDENCE: Each individual has a care plan which identifies users needs but these need further expanding to contain more detail and cover the individual specific needs of service users. There was still no information in care plans to detail any history and monitoring of falls. Although daily progress sheets contained reference to Hatzfeld House Care Home DS0000028615.V349253.R01.S.doc Version 5.2 Page 13 events there is a need to log and evaluate the event of falls and document what action is being taken to prevent further occurrence. The nutritional needs of service users are covered within the initial assessment document but care plans still do not provide tools for monitoring and review of individual needs and it is strongly recommended that a nutritional risk assessment tool be introduced within the care plan structure. There are some gaps in healthcare information but staff are able to think in a person centred way and are able to give a verbal update. Attention is needed to ensure care plans are initiated when needs change for example for depression and in following up blood sample tests and other medical tests. The home has a medication policy which is accessible to staff, medication records are up to date for each resident and medicines received, administered and disposed of are recorded. The home understands the need to comply with the administration, safekeeping and disposal of controlled drugs. Medication systems do not always follow good practice or safe practice guidelines and needs action to ensure staff only sign the medication record chart after they have visibly seen the service user take the medication dispensed. A requirement was set at the previous inspection and this practice must cease to ensure service users are not placed at risk. Staff are aware of the need to treat individuals with respect and to consider dignity when delivering personal care. A relative commented that her relative looks much better after recently moving into the home and that her relative’s health and welfare improved enormously. Hatzfeld House Care Home DS0000028615.V349253.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users enjoy their food and are helped to exercise choice and control over their lives, however the provision for social, cultural, religious and recreational interests and needs of service users could be improved. EVIDENCE: There was little evidence of any organised activities in the home records showed these mainly currently includes, nail care, hair care, occasional bingo, card games, TV, Church Service on TV, and an entertainer periodically. The views of those service users spoken with were that the activities provided were adequate as most service users would not physically be able to participate in many activities. Hatzfeld House Care Home DS0000028615.V349253.R01.S.doc Version 5.2 Page 15 The introduction of personal life history profiles would provide information about service users previous interests and hobbies that could be used to provide them with a more stimulating environment. A relative commented “ The standard of food is excellent, mum is a fussy eater, she doesn’t eat vegetables, she likes peas and they have provided them everyday for her. Plenty of drinks are provided and night staff have sat with mum with a cuppa to reassure her with their kindness. She enjoyed a singsong last week with war songs. Mum has forgotten to knit and crotchet due to her Alzheimer’s. The cleaning lady has taught her to knit again without patterns and crotchet table mats which are in use around the home.” Evidence gathering in relation to the promotion of equality and diversity within the home was still sparse. An equal opportunities policy is in place. The Statement of Purpose produced does address, that care will be provided that is appropriate to age, ethnic background and personal characteristics, and will promote advocacy and independence. Care plan formatting should address these topics in more detail. Policies, procedures and guidance promote individual independence and the right to live in a flexible environment where their choice of routines and activities are met when possible. Systems for checking practice are not always evident. Visitors said they were made welcome. Two meal options were written on the menu board, observation and confirmation by service users evidenced that service users were given an informed choice of meal options. Where menus are changed the reason for this should be recorded. The records kept for meal taken by service users were not consistent. Improved record keeping in this area is therefore required. Service users spoken with expressed satisfaction with the food. It is recommended that a service user survey be carried out in relation to food options/menu so that all service users can participate in the creation of the menu in conjunction with nutritional values and variety. Hatzfeld House Care Home DS0000028615.V349253.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have the information they need, should they wish to make a complaint and are safeguarded by policies and practice used in the home. EVIDENCE: The service has a complaints procedure in the Service users guide, which meets the National Minimum Standards and Regulations. Service users say they know how to make a complaint and staff are aware of the complaints procedure. There were no complaints recorded since the previous inspection. Policies and procedures for safeguarding people who use the service are in place and staff, are familiar with the guidance. There have been no safeguarding adults issues in the last twelve months. Staff have training on the topic of Safeguarding Adults in their care. Hatzfeld House Care Home DS0000028615.V349253.R01.S.doc Version 5.2 Page 17 However it is recommended that the manager and her deputy undertake training in referral protocols. Recruitment practices have been improved. Hatzfeld House Care Home DS0000028615.V349253.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 24 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a clean, hygienic, comfortable, appropriately furnished and well-decorated environment. EVIDENCE: Service users benefit from a comfortable, appropriately furnished and well decorated environment, which provides specialist equipment, suitable lavatories and washing facilities and bedroom space to suit their needs and maximise their independence. People who use the services are encouraged to personalise their bedrooms. Hatzfeld House Care Home DS0000028615.V349253.R01.S.doc Version 5.2 Page 19 The shared areas provide a choice of communal space with opportunities to meet relatives and friends in private. At the previous inspection one service users room was noted to have non slip flooring as opposed to carpet, on discussion with the manager it was apparent that the flooring was put down prior to the service user moving in to the home and there was no evidence that the flooring had been discussed with the service user or an alternative carpet offered. There was still no evidence that any action had been taken to rectify this. The bathrooms and toilets are fitted with appropriate aids and adaptations to meet the needs of the people who use the service, and are in sufficient numbers and of good quality. . Not all service users have lockable facilities provided in their bedrooms and this needs to be rectified. At the previous inspection it was identified that the bath hoist is also looking tired and requires attention to the enamel at the base. This had not yet been rectified. There are also some broken tiles in the bathroom extension which require repair and the manager was asked to undertake a risk assessment of exposed hot water pipes in the home particularly in the bathrooms. Good hygiene and infection control practices are in place and the home was clean and hygienic and smelled fresh throughout. Hatzfeld House Care Home DS0000028615.V349253.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Sufficient staff are provided who have basic training to do their jobs. However service users and staff would benefit by additional training on specific needs such as diabetes. Recruitment practices protect service users. EVIDENCE: There was training information available within the training records, which provided evidence of manual handling training, essential first aid, food hygiene, health and safety infection control; skills for care induction and foundation, and health and safety, fire training, Dementia Care and abuse awareness is covered within the induction; certificates were seen as evidence for this. Training is not however provided to meet the specific needs of service users with diabetes, mental health needs or catheter care. Hatzfeld House Care Home DS0000028615.V349253.R01.S.doc Version 5.2 Page 21 Recruitment procedures have been improved. Two personal staff files were viewed and were satisfactory. The provider has undertaken a review of the staffing levels since the last inspection and the manager now works full time super-numery in respect of her responsibilities. Three care staff assist service users during the daytime hours and two staff are provided at night Sufficient catering hours domestic and laundry are now provided. The manager undertakes supervision of staff. Individual practice observations sessions should be included and at least six sessions a year in total should be documented. All staff have now been issued with a copy of the General Social Care Councils Code of Conduct Booklet. Service users and a relative spoken with said that staff, were excellent and kind and nothing was too much trouble for them, these comments were extended to the manager also. Hatzfeld House Care Home DS0000028615.V349253.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service is run in the best interests of those who reside in the home with some quality monitoring systems in place. There was not sufficient evidence in place, however to show that service users financial systems are protected by the home as these records were still not available. The health and safety of service users is promoted and protected. EVIDENCE: The manager has the necessary experience to run the home; she has completed the Registered Managers Qualification but has not yet received the Hatzfeld House Care Home DS0000028615.V349253.R01.S.doc Version 5.2 Page 23 certificate, due to unforeseen circumstances. Staff service users and relatives spoke highly of the manager and her approachability. Records were viewed of the annual gas safety and the five yearly electric safety certificates, legionella and servicing of equipment, these were satisfactory. There was evidence of quality monitoring systems in effect at the home such as service user surveys and provider visits. It is recommended that systems are further developed to include relatives and visiting professionals. As at the previous inspection, a sample of service users financial records could not be examined, as these were not available for inspection. An Urgent Requirement has been set in respect of this continued breech of regulation. Failure to comply with this regulation is an offence. Also identified at the previous inspection, there needs to be a policy in place for the handling of service users finances and which clearly gives detailed guidance and instruction to staff to ensure service users are protected from any potential financial abuse. There were no issues identified at this inspection in relation to food safety and which the Environmental Health officer had also confirmed at a recent visit. There were no other health and safety issues identified. Hatzfeld House Care Home DS0000028615.V349253.R01.S.doc Version 5.2 Page 24 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 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 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 1 2 1 3 Hatzfeld House Care Home DS0000028615.V349253.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES 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. 1 Standard OP9 Regulation 13 [2] Requirement 1, Staff must only sign the medication record after visibly observing that the service user has taken the medication. Inaccurate records mean that it is not possible to be sure whether residents have received their medicines as prescribed PREVIOUS TIMESCALE 04/06/07 NOT MET. Regulation 13(2) of the Care Homes Regulations 2001 requires you to make arrangements for the storage, safe administration and recording of medicines. Failure to comply with this regulation is an offence. 2 OP15 OP37 17 Schedule 4 [13] Ensure that records are completed appropriately and available for inspection at all times in relation to: The meals eaten by service users in sufficient detail to enable any person inspecting the record to Hatzfeld House Care Home DS0000028615.V349253.R01.S.doc Version 5.2 Page 26 Timescale for action 11/11/07 11/11/07 determine whether the diet is satisfactory, in relation to nutrition and otherwise and any special diets prepared for individual service users. Where changes are made to the menu this should be documented and a record kept of the reason for this. Make good the enamel on the 11/11/07 base of the bath hoist. Ensure the broken tiles in the extension bathroom are repaired. Ensure lockable facilities are provided in all service users rooms. This will ensure the home is suitably maintained for service users safety and privacy. Ensure that records are completed appropriately and available for inspection at all times in relation to: Service users finances Records of the above are required by regulation for the protection of service users. PREVIOUS TIMESCALE 04/07/07 NOT MET. URGENT ACTION REQUIRED. Failure to comply with this regulation is an offence. 5 OP30 18 Provide staff with training in: Diabetes Care, Mental Health difficulties Hatzfeld House Care Home DS0000028615.V349253.R01.S.doc Version 5.2 Page 27 3 OP19 23 4. OP37 OP35 17 11/10/07 11/01/08 Catheter Care. This will ensure staff have the necessary skills to fully meet service users needs. 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 OP3 OP12 The introduction of personal life history profiles would provide information about service users previous interests and hobbies that could be used to provide them with a more stimulating environment. 2. OP3 Use assessment tools for the assessment of nutritional screening. Provide a separate page for each individual care plan on each identified need, such as diabetes, pressure areas, nutritional needs etc and record reviews on the back of each sheet. Further improve and update the care plans as discussed with the inspector. Ensure medical tests are followed up and recorded. Include the provision of keys to lockable facilities with the risk assessment for bedroom door keys. Good Practice Recommendations Expand the care plan documentation to include a running history of falls and expand on the cultural and diversity needs of service users. 3. OP7 Hatzfeld House Care Home DS0000028615.V349253.R01.S.doc Version 5.2 Page 28 4 5 OP8 OP19 6 7 OP19 OP30 Ensure risk assessments are completed in respect of denture soak tablets and all parties are informed of their risk. Where carpet is not provided in service users bedrooms, evidence should be provided of discussion and agreement in respect of this and /or any offer of replacement carpet to be fitted. Risk assessments are needed for hot water pipe work throughout the home, but particularly in bathrooms. Incorporate equality and diversity within the framework of services in the home and train staff accordingly. The manager and deputy manager should undertake training in care planning and referral protocols for safeguarding adults. 8 OP33 Implement a service user/relative survey in relation to the change of menus and evaluate feedback and demonstrate action taken. Expand the service user surveys to visiting professionals and relatives. Ensure that questionnaires sent from the Commission for Social care are issued to each service user and/or their representatives personally rather than left out in the reception. 9 10 OP33 OP35 Set up service user/relative meetings. Implement a detailed policy and robust financial procedures in relation to service users personal monies. 11 12 OP36 OP38 Supervision meetings should take place at least six times a year and include observations of practice and competency assessments for medication administration etc. Ensure risk assessments for manual handling tasks are fully completed in respect of staff and meet with the employer obligations under The Manual Handling Operations Regulations. Consult with the Environmental Health Officer for further advice. DS0000028615.V349253.R01.S.doc Version 5.2 Page 29 Hatzfeld House Care Home Hatzfeld House Care Home DS0000028615.V349253.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Hatzfeld House Care Home DS0000028615.V349253.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!