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Inspection on 04/04/06 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 4th April 2006.

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

The overall care provided for service users is good. 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. Care plans were noted to identify likes and dislikes but preferences in relation to bathing/showering preferences/frequency and preferred times for going to bed and getting up were not covered. Service users confirmed these choices were respected however. Service users were dressed appropriately and confirmed staff promotes independence both for personal care and dressing and in choosing their clothing for the day. Service users presented well cared for and appropriately dressed. The inspector observed staff using hoists to assist service users with mobility and staff treated service users with patience and kindness. Service users and a relative spoken with were happy with the services provided and said that their privacy and dignity was respected. They reported that they were happy with the food and the activities provision and that they felt confident to make complaints. Service user comments included the following Statements " Staff do all they can to help" " If you need anything, you just have to speak up" The numbers and skill mix of staff meets service users needs. Staff have some training to do their jobs but further evidence is needed to ensure this is fully up to date for all staff employed by the home. 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. Rooms viewed by the inspector were comfortable, clean and maintained and noted, to be very personalised. On the day of inspection there was no malodour observed. The home was observed to be, well maintained and kept clean. The health and safety of service users is generally promoted and protected.

What has improved since the last inspection?

The manager is registered with CSCI and has almost completed the Registered Managers Award. A Statement of Purpose has been devised and service users are now informed in writing that the home can meet their needs. The systems in place for the assessment of service users needs and the care plan structure are much improved; as is the management of medication. Recruitment practices in relation to PoVa List [Protection Of Vulnerable Adults list] checks and criminal records disclosures are now met. Eight radiators identified as high risk to service users have been fitted with covers The window in the staff toilet on the first floor was now restrained The outstanding requirements in relation to the provision of window restrictors; door locks to bedrooms, and other issues are identified in relation to the drive and night lighting of this and the grounds have been partly addressed. There was some evidence of water outlet temperatures testing. There was minimal evidence of quality monitoring systems in effect at the home. A service users questionnaire has been devised.

CARE HOMES FOR OLDER PEOPLE Hatzfeld House Care Home 10b Mansfield Road Blidworth Nottinghamshire NG21 0PN Lead Inspector Jayne Hilton Key Unannounced Inspection 4th April 2006 08:00 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.V287969.R01.S.doc Version 5.1 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.V287969.R01.S.doc Version 5.1 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 Mr Roger Willis Tracey Julia Graham Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23) of places Hatzfeld House Care Home DS0000028615.V287969.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service Users shall be within category OP Date of last inspection 4th January 2006 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. Range of monthly fees-information not obtained for this inspection Tracey Graham was Recently Registered with CSCI as manager. Hatzfeld House Care Home DS0000028615.V287969.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Regulation Inspector Jayne Hilton carried out the unannounced key inspection for duration of six hours. The key standards were assessed under the new methodology of Inspecting for Better Lives [IBL] and included indirect and direct observation of practice and interaction, a part tour of the building, the examination of care plans and other associated documentation and records to case track two individuals in detail. Another service users care plan was sampled also. The management of medication was partly assessed and the systems in place for health and safety, food and nutrition. One relative was interviewed and two service users were interviewed at this inspection due to the time taken for the other areas of inspection. Four staff members were spoken to about various issues throughout the inspection. The new manager has been registered by CSCI recently. Overall progress has been made in raising the standards of the home to meet with The Care Home Regulations 2001 and associated National Minimum Standards. Those service users spoken with and a relative praised the home and clearly outcomes for those residing in the home are good. There are however some outstanding requirements and an agreement was made with the Registered Manager that these will be complied with by May 9th 2006. Failure to comply on those requirements specified for this date will result in an immediate requirement Notice being issued and Enforcement Action instigated. Equality and Diversity issues need to be promoted more within the home and Quality Monitoring as this is integral to all aspects of the service provision and outcomes for service users and this must be implemented fully at once. What the service does well: The overall care provided for service users is good. 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. Care plans were noted to identify likes and dislikes but Hatzfeld House Care Home DS0000028615.V287969.R01.S.doc Version 5.1 Page 6 preferences in relation to bathing/showering preferences/frequency and preferred times for going to bed and getting up were not covered. Service users confirmed these choices were respected however. Service users were dressed appropriately and confirmed staff promotes independence both for personal care and dressing and in choosing their clothing for the day. Service users presented well cared for and appropriately dressed. The inspector observed staff using hoists to assist service users with mobility and staff treated service users with patience and kindness. Service users and a relative spoken with were happy with the services provided and said that their privacy and dignity was respected. They reported that they were happy with the food and the activities provision and that they felt confident to make complaints. Service user comments included the following Statements “ Staff do all they can to help” “ If you need anything, you just have to speak up” The numbers and skill mix of staff meets service users needs. Staff have some training to do their jobs but further evidence is needed to ensure this is fully up to date for all staff employed by the home. 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. Rooms viewed by the inspector were comfortable, clean and maintained and noted, to be very personalised. On the day of inspection there was no malodour observed. The home was observed to be, well maintained and kept clean. The health and safety of service users is generally promoted and protected. What has improved since the last inspection? The manager is registered with CSCI and has almost completed the Registered Managers Award. A Statement of Purpose has been devised and service users are now informed in writing that the home can meet their needs. The systems in place for the assessment of service users needs and the care plan structure are much improved; as is the management of medication. Recruitment practices in relation to PoVa List [Protection Of Vulnerable Adults list] checks and criminal records disclosures are now met. Eight radiators identified as high risk to service users have been fitted with covers The window in the staff toilet on the first floor was now restrained The outstanding requirements in relation to the provision of window restrictors; door locks to bedrooms, and other issues are identified in relation to the drive and night lighting of this and the grounds have been partly addressed. Hatzfeld House Care Home DS0000028615.V287969.R01.S.doc Version 5.1 Page 7 There was some evidence of water outlet temperatures testing. There was minimal evidence of quality monitoring systems in effect at the home. A service users questionnaire has been devised. What they could do better: There was minimal evidence of quality monitoring systems in effect at the home. There was no evidence of systems in place to prevent legionella. The Registered Person must seek advice from the Environmental Health officer regarding this and provide the inspector with a copy of the outcome. Prospective service users and existing service users do not have all of the up to date information they need to make an informed choice about where they live. Amendment to The Statement of Purpose is required. The process for assessment, review and evaluation of changing needs of service users needs to be further improved to ensure all service users needs are fully met. Further maintenance and lighting to the grounds is needed to ensure service users are safe. Attention is needed in relation to security of exit doors and window restrictors. The training provision needs to be improved to ensure the mandatory topics are covered sufficiently and for other assessed needs of service users. Staff also needs to have training available to ensure service users are protected from abuse. There is no system yet in place for staff supervision and the overall record keeping of staff personal records appears disorganised. Requirements are set in relation to staff personal files, for evidence of suitable training, for full implementation of quality monitoring, for systems to be put into place for the prevention of legionella, for staff supervision to be implemented, for amendment of the statement of purpose and service users guide and safety and security of the environment and grounds. Several good practice recommendations have been made particularly in relation to menu options and for meeting the nutritional needs of service users. Please contact the provider for advice of actions taken in response to this Hatzfeld House Care Home DS0000028615.V287969.R01.S.doc Version 5.1 Page 8 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Hatzfeld House Care Home DS0000028615.V287969.R01.S.doc Version 5.1 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.V287969.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2, 3,4 Prospective service users and existing service users do not have all of the up to date information they need to make an informed choice about where they live. Contracts are provided service users and they have written confirmation that the home can meet their assessed needs. 3, 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. Service users are confident that their needs are being met. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service.” EVIDENCE: Hatzfeld House Care Home DS0000028615.V287969.R01.S.doc Version 5.1 Page 11 A Statement of Purpose has been devised which has some of information as required to meet with the regulation/Schedule 1 and was on display in the reception area of the home. Missing information was identified as follows: • • • • • • • Name of Registered Provider/background and qualifications of Registered Provider. Background and Qualifications of Registered Manager. Registration Category of Service users catered for, sex of service users, age range and needs catered for. Needs to be clear that the home does not Provide Nursing. Emergency Admissions should only be considered where the home has obtained a full assessment of needs of the individual More information about how the social and leisure needs of service users will be assessed and provided for. The arrangements for reviewing Service users Care/Care plans with service users or their representatives and Quality Monitoring, other than Social Services Formal Reviews Room sizes and numbers Therapeutic Techniques provided/not provided etc. • • There still did not appear to be a service user guide available and if this document is to be combined with the statement of purpose, the relevant information as specified by standard 1, regulation 5, also needs to be included in the statement of purpose document. There was no evidence of copies in service users rooms and service users and relatives spoken with could not recall being issued with a copy. A brochure was seen but this was not sufficient in detail to meet the regulations. Hatzfeld House Care Home DS0000028615.V287969.R01.S.doc Version 5.1 Page 12 As part of the admission process, it is good practice to include the issue of a service user guide with the terms and conditions or contract and for the service user or relative to sign that they have received a copy, which then can be kept in the service users personal information. The registration certificates were displayed clearly. There was a copy of the last inspection report on view; and there was information viewed in the Statement of Purpose regarding how service users or relatives could access this. The Terms and Conditions pr-forma was evidenced. The room number needs to be included. Evidence was provided of terms and conditions for a newly admitted service user and the Two-service users case tracked. There was also evidence that the registered provider informs the service user in writing that the home can meet their needs. A sample of service users care plans was examined as part of the assessment process for the requirements set at the previous inspection. The Registered manager was advised again that extended community care assessments should be kept within the care plan file. The registered manager or the deputy visits prospective service users to carry out a pre – assessment. The assessment document now used does not quite meets with standard 3 of the NMS as there is no section for history of falls, foot care or continence. Some Care plans contained life history portfolios, which were useful for assessing service users lifestyles, interests and hobbies, but these were not seen in all plans. There was now evidence of a missing person policy available and work had progressed on risk assessments in service users personal information should they wander or goes missing. The manager informed the inspector that there were no service users in residence at the moment with an identified risk of wandering, however a missing person identification sheet for each service user should be devised as part of this and placed within each file should the service user go missing. 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 but preferences in relation to bathing/showering preferences/frequency and preferred times for going to bed and getting up were not covered. Service users confirmed these choices were respected however. Service users were dressed appropriately and confirmed Hatzfeld House Care Home DS0000028615.V287969.R01.S.doc Version 5.1 Page 13 staff promotes independence both for personal care and dressing and in choosing their clothing for the day. Hatzfeld House Care Home DS0000028615.V287969.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Service users health, personal and social needs are generally set out in the present system. The system 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. The current system for the management of medication is noted to be much improved, further work is recommended in relation to further developing and defining specific medicine policies. Service users feel they are treated with respect and their right to privacy is upheld. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans viewed had been improved since the last inspection and provided a good overview of individual service users needs however the content does not specify fully detailed actions to be taken by staff to meet individual service users needs (Standard 7.2) and need expanding to contain more detail and Hatzfeld House Care Home DS0000028615.V287969.R01.S.doc Version 5.1 Page 15 cover the individual specific needs of service users. Bathing and bedtime preferences, behaviour, and specific diabetes related monitoring for foot care and eyesight issues were found to be missing. Several care plans are documented on one page, which limits the space for appropriate monitoring, evaluation and review of the plan. It is recommended that separate sheets are used for each individual plan of care, and the back of the sheet to contain evidence of cross referencing of specific issues noted in daily logs and any changes etc. Review dates were recorded monthly in two out of the three sampled but there was no evidence of evaluation and review of service users changing needs or reassessment of needs. The inspector was able to evidence service users involvement with the initial care planning process but not for review/ongoing consultation and evaluation of care. There was also evidence that service users had been consulted in relation to door keys and privacy nets/blinds and use of restraint such as bedrails. The inspector viewed recorded evidence of service users receiving health care assessments from the auditory, opticians, dentist and follow up appointments with the hospitals. Weight records were in place and care charts. Nutritional needs are covered within the initial assessment document but care plans 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. General risk assessments were present and the manager has completed mobility information. Manual handling risk assessments were found not to be fully completed in the identification of risk to carers and the individual. There was still no information in care plans to detail any history of falls. Although daily progress sheets contained reference to events there is a need to log and evaluate the event of falls and document what action is being taken to prevent further occurrence. Waterlow risk assessments are used to evaluate if service users are at risk of developing pressure areas. No service users were reported to have pressure sores on the day of the inspection. Service users with identified risks of developing pressure sores had care plans in place, which identified which equipment should be in place. Specialist equipment was observed, to be provided for those, requiring pressure area prevention. Continence appeared to be well managed but documentation for this within the care plan is needed. Service users presented well cared for and appropriately dressed. The inspector observed staff using hoists to assist service users with mobility. Some observed manual handling techniques was questioned with the staff and manager and evidence of up to date and current safe practices training is required. Hatzfeld House Care Home DS0000028615.V287969.R01.S.doc Version 5.1 Page 16 The inspector directly observed the manager dispensing and administering medication. Staff have undertaken medicines management training and the manager has documented a review of medicines training. Competency assessments of individual staff,however should be documented within the staff personal training and development records. An adequate medication policy was in place and a policy for medication errors has now been implemented. Policies should be further developed in line with The Royal Pharmaceutical Society’s Guidance manual for The Safe Handling of Medicines in Care Homes. It was reported by staff that there are no service users currently selfadministering medication but risk assessments should be prepared in line with a policy for self - administration. Photographs are used and evidence was in place of sample signatures at the front of the mars for those responsible for administering medication. The manager reported that storage temperatures were now monitored but the inspector did not check records for this, at this inspection. A trolley has been purchased and the practice of administration of medicines is therefore safer and overall much improved. Advice was provided to the manager at the previous inspection to obtain and to ensure that the Royal Pharmaceutical guidelines for safe administration of medication (page 18) (Standard 9.1) are in place and followed by staff. Indirect observations evidenced that staff were interacting appropriately with service users. Service users confirmed that staff respected their privacy and dignity at all times. A pay phone is available within the main reception area. Hatzfeld House Care Home DS0000028615.V287969.R01.S.doc Version 5.1 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13,14,15 The provision of social, cultural, religious and recreational interests and needs could be improved. Service users can maintain relationships with friends and family. Service users are helped to exercise choice and control over their lives. Service users report that they enjoy the food. The nutritional needs of service users are not being fully met. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The inspector examined recorded evidence of documentation of individual service users personal and social history on some service users files. A folder provided information of entertainers and local events, which staff can book. The information regarding the provision of activities was minimal and staff reported that although they endeavour to organise dominoes and bingo etc, the service users in the home were not very motivated to participate. The responsibility of activities was of day staff before lunch usually. Staff record of the activity provided and who participated but are not recording whether service users have been asked to join in and have refused. The records examined included two/three entries on average a week for individuals Hatzfeld House Care Home DS0000028615.V287969.R01.S.doc Version 5.1 Page 18 and included hairdressing and visitors. The views of those service users and a relative spoken with were that the activities provided were adequate as most service users would not physically be able to participate in many activities. Through discussion with the relative, the manager and the service users, it was identified that if the social history profiles and service users surveys were being actively used, specific interests of service users could be explored and ideas created from this such as themed events and bringing animals in to the home schemes. The service users and staff would clearly benefit from the provision of an activities co-ordinator and some innovative and creative ideas should be introduced and based on the assessed social needs of service users. A weekly activities programme has been devised and currently includes, nail care, hair care, bingo, card games, TV, Church Service on TV, and an entertainer periodically. Service users and a relative reported that a church minister attends the home monthly. A relative reported that a chair exercise class used to be organised some time ago. The assessment and care plans and discussion with the manager and service users evidenced that service users were encouraged to be as independent as possible and that, choice and autonomy were respected by staff working in the home. Bedrooms were observed, to be, personalised. Service users should be provided with information of how to access their personal records in accordance with the data protection Act 1998. Visitors are made welcome at any reasonable time and the acting manager is to develop the service users guide in relation to informing service users how relationships will be supported and maintained. Evidence gathering in relation to the promotion of Equality and diversity within the home was sparse. An equal opportunities policy is in place, but there was no evidence of any training for staff in equality and diversity. 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. 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 and a record was being kept of this. Diabetic diets are provided for. The cook reported that she was not using prepared menus and that she decided on a daily basis what she would offer and it appeared that one service users dietary needs were dominating what was prepared and offered to all service users. Whilst it is recognised that effort has been made to approach an individuals dietary needs, this did appear to affect the overall balance of nutritional and variance of menu items offered. Service users spoken with expressed satisfaction with what was provided and the cook did endeavour to provide three roast meat dishes over a week and a fish option. The cook had not got any information on nutritional values of food and Hatzfeld House Care Home DS0000028615.V287969.R01.S.doc Version 5.1 Page 19 would benefit from training in this area and in devising suitable prepared menu options, which would suit all service users. 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. Where individuals do not then take adequate nutrition by choice this should be fully documented and charted. It was reported that the budget for food provision had not been revised for six years and therefore the Registered Provider is asked to review this. Hatzfeld House Care Home DS0000028615.V287969.R01.S.doc Version 5.1 Page 20 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Service users and their relatives are confident that their complaints will be listened to and acted upon. Service users are protected from abuse. Further training is recommended. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A complaints policy is on display in the main reception but this appears to need updating. The complaints procedure does not state the timescale for response. One complaint was documented and appeared to have been resolved. A format for documenting complaints is in place but need to identify if complaint is upheld, not upheld, unresolved etc and needs to identify where information in respect of any investigation is to be kept if not kept with the complaint. Service users and a relative spoken with confirmed that they were confident to make a complaint should they have any to make, but were not aware of the official procedure. Once the service user guide is distributed this will provide service users with the appropriate information. No Complaints have been received by CSCI since the previous inspection. The policy for adult protection was seen. There was some evidence of training provided for adult protection [although it is covered as part of the initial induction]. All staff should undertake training in adult protection. Hatzfeld House Care Home DS0000028615.V287969.R01.S.doc Version 5.1 Page 21 The manager reports no Adult Protection investigations for the home in the past twelve months. A service user case tracked highlighted practices in place to protect the service user and staff in relation to monies held in a purse. The approach was agreed by the service users relatives but had not been formally agreed within a care plan and because of the involvement of several relatives the system in place appeared inconsistent and needed to be revised and balances kept. The manager had risk assessed the issue and the relatives had agreed to only small amounts being held by the service user, however if the system is to be appropriate tighter monitoring is needed and formalised and agreed within a care plan. Service users are provided with a lockable facility in their rooms but there was no evidence in place that service users had been issued/offered keys or risk assessed for this. The manager has devised documentation in relation to keys for bedroom doors and risk assessments were seen where it had been assessed that service users were not able to hold a key. However where service users may not be able to use a key themselves, the assessment should cover where staff may need to lock the bedroom door on behalf of the service user. A service user with some behaviour that challenges the service, did not have a care plan in place for how staff manage this. Staff, were recording incidents in relation to this in the daily notes, but this needs formalising into a care plan. [See standards 7,8] Risk assessments were provided where service users need mechanical restraint such as use of bedrails etc. Hatzfeld House Care Home DS0000028615.V287969.R01.S.doc Version 5.1 Page 22 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,24,25,26 Service users benefit from a clean, hygienic, comfortable, appropriately furnished and well-decorated environment. Further maintenance and lighting to the grounds is needed to ensure service users are safe. Attention is needed in relation to security of exit doors and window restrictors. The service provides specialist equipment, suitable lavatories and washing facilities and bedroom space to suit their needs and maximise their independence. Service users rooms were overall safe and personalised. Further work is needed in relation to the water storage/systems to prevent legieonella. The home is clean, pleasant and hygienic. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has three lounge areas and a designated dining area. In general, furnishings in communal areas are of a homely appearance and the decoration Hatzfeld House Care Home DS0000028615.V287969.R01.S.doc Version 5.1 Page 23 of a high standard. There is an enclosed garden accessible to service users that is generally safe and well maintained. The security systems and night lighting for the exterior of the home is currently being reviewed and this has been highlighted as needed by the health and safety audit carried out. Some improvement has been made but further lighting is needed. The manager has fully risk assessed the grounds and made recommendation and request for flood lighting to the driveway etc. There is a pond, which is going to be filled in. Hoists call alarms and grab rails were observed in the home and a passenger lift provides access to the first floor. Rooms viewed by the inspector were comfortable, clean and maintained. Observation of rooms noted, to be very personalised. Radiators have been fitted to priority risk areas. The inspector advised at the previous inspection for the manager to seek advice from the Environmental Health Officer, regarding the heating and water systems to ensure that the system is adequate in the prevention of legionella. This had still not been actioned, but the manager said she had spoken to a plumber for advice and there was evidence of water outlet safe temperatures to prevent scalding, testing for bedrooms and bathrooms. There was however no evidence of systems in place for legionella and this must be rectified urgently. Work has been progressed regarding fitting windows on the ground floor with a suitable retainer. A bedroom window was noted to have been missed. Exit doors are not alarmed and one door leading to the annexe courtyard posed a risk to service users was identified as a risk to service users should they use this door to go outside alone. The ground is not levelled. Action must be taken to ensure the exit doors and grounds are safe and secure. On the day of inspection there was no malodour observed. The home was observed to be well maintained and kept clean. During the tour of the accommodation the inspector evidenced a warm and comfortable environment. The laundry facilities were assessed as adequate but the laundry room was not kept locked when not in use. Action should be taken to ensure service users safety in relation to access to this area. Staff were observed to use personal protective clothing and ample supplies observed around the home. Staff have recently undertaken training in infection control. Hatzfeld House Care Home DS0000028615.V287969.R01.S.doc Version 5.1 Page 24 Hatzfeld House Care Home DS0000028615.V287969.R01.S.doc Version 5.1 Page 25 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,29,30 The numbers and skill mix of staff meets Service users needs. More information, is required in relation to recruitment and information on staff. Staff have some, training to do their jobs but further evidence is needed to ensure this is fully up to date for all staff employed by the home. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Rotas were examined and demonstrated adequate staffing levels to meet the needs of service users. The rota format is not easy to assess and should identify what shift each individual is working on each day. Domestic/Laundry and Catering hours are satisfactory but clearer documenting of these is needed. There was some training information available but there was not a training programme available to outline training needs of staff for the following twelvemonth period. Neither were there any individual staff files for their personal development, training and supervision/appraisal. The information provided/kept for training was disorganised and inconsistent. There was evidence of manual handling training, essential first aid, food hygiene, infection control; skills for care induction and foundation. Hatzfeld House Care Home DS0000028615.V287969.R01.S.doc Version 5.1 Page 26 The manager reported that health and safety, fire training and abuse awareness is covered within the induction but evidence of detailed training is needed. The manager informed the inspector that on site training is provided in the porta cabin and that some staff have attended training for dementia care in the past. There was evidence that one senior staff member had attended fire safety training recently. The personal files of staff need to be organised and contain evidence of training, certificates etc and evidence of any training achieved in previous employment needs to be kept also. The acting manager reported that she would supply the inspector with the necessary details. Training had not been arranged within the timescale allowed. One member of staff confirmed that some health and safety training had been covered in the initial induction, but could not offer detailed evidence of the contents of the training. It was also reported that the training offered was combined with the training for the domiciliary service care staff and was based on domiciliary care rather than tailored to meet the needs of those working at the care home. Arrangements have been made for the manager to be able to access the information that must be available for inspection, however on the day of the inspection a training course was in place and evidence not provided as previously requested. A requirement is therefore set for the Registered Provider to provide CSCI with evidence on the following: • • • • Evidence of the Manual Handling Trainers, training details and that training techniques provided recently are safe and current. Evidence of the content of the Health and Safety Training, Fire Training and abuse awareness provided for staff in induction. Evidence of up to date training for all existing staff members in Health and Safety, Fire safety and Abuse Awareness. Evidence of NVQ training for and numbers achieved. This information must be submitted to CSCI by 9th May 2006, Failure to do so may result in Enforcement Action Being taken. The immediate requirement set in relation to recruitment practices at the previous inspection was evidenced as met, however a check on staff personal files was unsuccessful, as information was not provided to assess all staff files were completed. The personal file of a newly employed staff member was missing some of the required documentation in relation to schedules 2 and 4 of the Regulations. Hatzfeld House Care Home DS0000028615.V287969.R01.S.doc Version 5.1 Page 27 This requirement is therefore outstanding and an agreement made that all will be accessible within an agreed timescale by 9th May 06. Hatzfeld House Care Home DS0000028615.V287969.R01.S.doc Version 5.1 Page 28 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38 The manager is registered with CSCI and has almost completed the Registered Managers Award. There is minimal evidence of quality monitoring systems in place. 35, Service users financial systems are generally protected by the home, however improved policies and procedures are needed to ensure these are robust. There is no formal supervision of staff. The health and safety of service users is generally promoted and protected. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager is registered with CSCI and has almost completed the Registered Managers Award. She was able to demonstrate evidence that a copy of the NMS and Care Home Regulations was in use. Hatzfeld House Care Home DS0000028615.V287969.R01.S.doc Version 5.1 Page 29 There was minimal evidence of satisfactory quality monitoring systems in effect at the home. The manager provided evidence of a service users questionnaire that is to be carried out. The manager and staff were advised to carry one out promptly and to consider the subject of food, nutrition and menus to be the topic. Evidence of regulation 26 visits by the provider and the report were provided. The manager had completed the most recent however and not the Registered Provider. The Registered Person must ensure that more suitable Quality monitoring systems and audits are put into place by 9th May 2006. A sample of service users financial records were examined at the previous inspection and found to be satisfactory. The systems for service users finances were assessed in relation to Standard 18 and a case tracking issue, but not inspected at this inspection due to time constraints and information being held where training was taking place. At the previous Inspection it was not clear if the provider was an appointee for the two service users discussed at the inspection. The provider should provide information to the commission regarding the appointee ship if this is the case and consider making the appropriate arrangements to change this if possible. Secure facilities are provided for safekeeping of money and valuables but there was not a system in place for receipting for this practice. There needs to be a policy in place for the handling of service users finances and which clearly gives guidance and instruction to staff to ensure service users are protected from any potential financial abuse. As no evidence has been provided in relation to the above the recommendations are carried forward for action by the Provider. Formal supervision is not in place and this needs to be implemented as specified in Standard 36.1-36.5 and Regulation 18. This is an outstanding requirement and must be implemented by May 9th 2006 to avoid enforcement action. A fire risk assessment is now in place and the acting manager reported that magnetic door closures were going to be installed. Risk assessments regarding the propping open of fire doors have been implemented. A fire drill has taken place. Some other work has been identified by the health and safety audit report. In addition the inspector has recommended the fire door situated on the first floor to be fitted with an alarm (Standard 38.2). Fire training and health and safety training was to be arranged with the homes training provider the week after the last inspection. The manager promised to provide evidence of this by the due target date. The training has not yet been achieved; Action must be taken by the target date to avoid enforcement action. There was no evidence of systems in place to prevent legionella. The Registered Person must seek advice from the Environmental Health officer Hatzfeld House Care Home DS0000028615.V287969.R01.S.doc Version 5.1 Page 30 regarding this and provide the inspector with a copy of the outcome. Outstanding. See Standard 25 Outcome. Hatzfeld House Care Home DS0000028615.V287969.R01.S.doc Version 5.1 Page 31 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 2 3 2 3 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 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 3 X X X 3 2 3 STAFFING Standard No Score 27 3 28 X 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 1 X 2 Hatzfeld House Care Home DS0000028615.V287969.R01.S.doc Version 5.1 Page 32 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 OP1 Regulation 4,5 Timescale for action Amend the Statement of Purpose 09/05/06 and Service User Guide to meet with the full Requirements Schedule 1. Ensure the home the exit doors and grounds are safe for use by service users and appropriately maintained. Ensure further night lighting is provided to the outdoor environment and driveway. Ensure the window identified at the inspection is fitted with a restrictor. Ensure the personal staff files contain the required evidence as specified in schedule 2 and 4 of the Regulations Outstanding. Failure to comply may result in Enforcement Action. Evidence for the following must be submitted to CSCI by the target date of 9/05/06 • Hatzfeld House Care Home Requirement 2 OP19 23 09/05/06 3 4 OP25 OP29 23 7,9,17,19 09/05/06 09/05/06 5 OP30 18 09/05/06 Evidence of the Manual Version 5.1 Page 33 DS0000028615.V287969.R01.S.doc Handling Trainers, training details and that training techniques provided recently are safe and current. • Evidence of the content of the Health and Safety Training, Fire Training and abuse awareness provided for staff in induction. Evidence of up to date training for all existing staff members in Health and Safety, Fire safety and Abuse Awareness. • Failure to comply may result in Enforcement Action. • Evidence of NVQ training for and numbers achieved. 6 OP33 25 Implement appropriate systems to monitor the quality of care provided. Previous timescale not met 24/12/05 Some evidence by 30/3/06. Continue to develop. 09/05/06 7 OP36 18 Implement formal supervision for 09/05/06 all staff. Outstanding Failure to comply may result in Enforcement Action. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Hatzfeld House Care Home DS0000028615.V287969.R01.S.doc Version 5.1 Page 34 No. 1. 2 3. 4. 5. 6. 7. 8 9. Refer to Standard OP1 OP2 OP3 OP3 OP7 OP7 OP8 OP9 OP12 Good Practice Recommendations Obtain a signature from service users or their representative for receipt of service user guide Include room number in the Terms and Conditions document Expand the assessment documentation to include history of falls, foot care, continence and mental health needs. Use assessment tools for assessment of nutritional screening. Provide a separate page for each care plan and record reviews on the back of each sheet. Further improve and update the care plans as discussed with the inspector. Include a running record of history of falls and incidents/events within the care plan. Further develop the medicines policies. Consider providing an activities co-ordinator and reviewing the activities provided to meet the identified social needs of service users. Incorporate equality and diversity within the framework of services in the home and train staff accordingly. Incorporate equality and diversity within the framework of services in the home and train staff accordingly Include more of service users preferences in the assessment and care plan i.e. bathing bedtimes etc Review the food budget Re-instate a set menu with choice options Provide training for staff in food nutrition, particularly the cook Ensure the complaints procedures on display are up to date and meet the standard. Provide training for staff for adult protection. Formalise the care plan for the identified service user re purse issues. Include the provision of keys to lockable facilities with the risk assessment for bedroom door keys. Provide an annual training programme for staff and set up DS0000028615.V287969.R01.S.doc Version 5.1 Page 35 10 11 12 13 14 15 16. 17 18 19. 20 OP12 OP14 OP14 OP15 OP15 OP15 OP16 OP18 OP18 OP18 OP30 Hatzfeld House Care Home individual staff personal training, development and supervision files for staff. 21. OP33 Implement a service user/relative survey in relation to the change of menus and evaluate feedback and demonstrate action taken Set up service user/relative meetings Implement a policy and robust financial procedures in relation to service users personal monies. Provide receipts for safekeeping of valuables. The provider should inform CSCI if he is the appointee for any service users finances. 24 25 26 OP38 OP38 OP38 Provide evidence in relation to recommendations from the Health and safety audit in relation to fire exit doors etc have been carried out. Ensure safety of service users in relation to access to the laundry area Ensure risk assessments for manual handling tasks are fully completed and meet with the employer obligations under The Manual Handling Operations Regulations. 22. 23 OP33 OP35 Hatzfeld House Care Home DS0000028615.V287969.R01.S.doc Version 5.1 Page 36 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: 0845 015 0120 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.V287969.R01.S.doc Version 5.1 Page 37 - 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. 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