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Inspection on 04/04/07 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 4th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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. 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 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 are lovely" "the staff are excellent" 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, on the whole, well maintained and kept clean. 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.Hatzfeld House Care HomeDS0000028615.V333495.R01.S.docVersion 5.2Page 7

What has improved since the last inspection?

Quality monitoring systems are now in effect at the home. A system is in place to prevent legionella. The training provision has been improved to ensure the mandatory topics are covered sufficiently. A system is now in place for staff supervision and the overall record keeping of staff personal records appears more organised.

What the care home could do better:

Eight requirements are made because: Recruitment practices fail to fully protect service users. This is an outstanding requirement from two previous inspections and the registered provider is required to take URGENT ACTION to ensure service users are safe from harm. Service users complaints are not fully documented or responded to. There was not sufficient evidence in place to support that service users financial systems are protected by the home. The health and safety of service users is not fully promoted and protected in respect of food safety practices and annual gas safety checks. The current system for the management of medication is not fully satisfactory and may place service users at risk. 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. 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. In addition twelve good practice recommendations are made.

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 2007 08:15 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.V333495.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.V333495.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 Old age, not falling within any other category registration, with number (23) of places Hatzfeld House Care Home DS0000028615.V333495.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service Users shall be within category OP Date of last inspection 23rd October 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 Weekly fees- £283 -£376 information was obtained from the registered manager at the inspection on 4th April 2007. Service users pay extra for personal newspapers, hairdressing and chiropody. Hatzfeld House Care Home DS0000028615.V333495.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 7 daytime hours. The main method of inspection used was called ‘case tracking.’ This involves selecting three 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. Three other care plans were examined also. 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. Four 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 pre-inspection questionnaire 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. A random inspection was carried out at the home, previously on 23rd October 2006. The reason for this inspection was to follow up the requirements set at the previous key inspection on 4th April 2006. Details of the outcome for the random inspection may be obtained on request in writing to the Commission for Social Care Inspection. What the service does well: Hatzfeld House Care Home DS0000028615.V333495.R01.S.doc Version 5.2 Page 6 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 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 are lovely” “the staff are excellent” 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, on the whole, well maintained and kept clean. 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. Hatzfeld House Care Home DS0000028615.V333495.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: Eight requirements are made because: Recruitment practices fail to fully protect service users. This is an outstanding requirement from two previous inspections and the registered provider is required to take URGENT ACTION to ensure service users are safe from harm. Service users complaints are not fully documented or responded to. There was not sufficient evidence in place to support that service users financial systems are protected by the home. The health and safety of service users is not fully promoted and protected in respect of food safety practices and annual gas safety checks. The current system for the management of medication is not fully satisfactory and may place service users at risk. 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. 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. In addition twelve good practice recommendations are made. Hatzfeld House Care Home DS0000028615.V333495.R01.S.doc Version 5.2 Page 8 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 be made available in other formats on request. Hatzfeld House Care Home DS0000028615.V333495.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.V333495.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 adequate. This judgement has been made using available evidence including a visit to this service. 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. 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. EVIDENCE: Service users needs are assessed before they move to the home. For residents who are self-funding the service is able to demonstrate how they have undertaken the assessment. They are generally undertaken Hatzfeld House Care Home DS0000028615.V333495.R01.S.doc Version 5.2 Page 11 satisfactorily, however the cultural and diversity needs of individuals should also be expanded upon within the documentation. There was no evidence of contracts available at this inspection or any evidence that the registered provider had confirmed to the service users that then home could meet their needs prior to their admission. Therefore there was no evidence to support that Individuals are provided with basic information on what people who live in the home can expect to receive for the fee they pay, or sets out terms and conditions of occupancy. The service users 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. Service users confirmed these choices were respected. Service users were dressed appropriately and confirmed staff promotes their independence. The service has developed a 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 made available to individuals in a standard format. Out of six service users plans viewed, only one service users personal information, provided evidence that a service users guide had been issued to service users or their representatives. The manager reported that as new service users move in they are being asked to sign they have received a 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. There was no evidence that any progress had been made in embracing Equality and Diversity within the home. There is a basic understanding of the manager and staff and some acknowledgement of addressing individual’s specific needs but this needs to be documented and evidenced. Two service users have their religious needs supported. Hatzfeld House Care Home DS0000028615.V333495.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 health, personal and social needs are generally set out in a plan of care. 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 not fully satisfactory and may place service users at risk. Service users feel they are treated with respect and their right to privacy is upheld. EVIDENCE: Each individual has a care plan but practice of involving people who use the service in the development and review of the plan is variable. The manager has been developing the system for care planning over the last twelve months but although care plans provided a good overview of individual service users Hatzfeld House Care Home DS0000028615.V333495.R01.S.doc Version 5.2 Page 13 needs and specify some actions to be taken by staff to meet individual service users needs and need further expanding to contain more detail and cover the individual specific needs of service users. Several care issues are documented on one page with further information in separate sections, which do not provide an easy reference for staff or the service user. 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. There was still no information in care plans to detail any history and monitoring 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. 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. Review dates were recorded monthly in the six sampled personal files. There was no evidence of service user involvement or agreement to the files seen and service users spoken with said they were not aware of their care plans. Attention is needed to ensure that all care plans are dated and signed by the person writing them. There is evidence in the care plan of health care treatment and intervention, and a record of general health care information. There are some gaps in information but staff are able to think in a person centred way and are able to give a verbal update. The home has a medication policy which is accessible to staff, medication records are generally 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. Where prescriptions have to be handwritten on the medication record two signatures are required as a record that the entry is correct and witnessed. Hatzfeld House Care Home DS0000028615.V333495.R01.S.doc Version 5.2 Page 14 Staff generally think in a person centred way when considering an individual’s personal care needs. Staff are aware of the need to treat individuals with respect and to consider dignity when delivering personal care. Hatzfeld House Care Home DS0000028615.V333495.R01.S.doc Version 5.2 Page 15 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, and15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The provision for social, cultural, religious and recreational interests and needs of service users could be improved. Service users are helped to exercise choice and control over their lives. Service users report that they enjoy the food. Improved documentation is needed to ensure the nutritional needs of service users are being fully met. 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 manager reported that she is looking at delegating the responsibility for activities to one member of staff but staff stated they have limited time for the provision of activities or that it was difficult to motivate service users that the home prioritise personal care needs of individuals. Hatzfeld House Care Home DS0000028615.V333495.R01.S.doc Version 5.2 Page 16 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. Evidence gathering in relation to the promotion of equality and diversity within the home was still 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. 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. 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 and soft diets are provided for. Service users spoken with expressed satisfaction with the food but said they would like more choice. 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. The food in the home is of satisfactory quality, well presented and meets the dietary needs of people who use the service. Care staff is sensitive to the needs of those residents who find it difficult to eat and give assistance with feeding. They are aware of the importance of feeding at the pace of the service user, making them feel comfortable and unhurried. Hatzfeld House Care Home DS0000028615.V333495.R01.S.doc Version 5.2 Page 17 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 poor. This judgement has been made using available evidence including a visit to this service. Service users complaints are not fully documented or responded to. Service users may be placed at risk because of poor recruitment practices. EVIDENCE: The service has a complaints procedure in the Service users guide, which meets the National Minimum Standards and Regulations. The procedure displayed in the home, however is still not up to date. Service users say they know how to make a complaint and staff are aware of the complaints procedure. Complaints from individuals are not always fully recorded and timescales, outcomes and actions are not being properly logged. One complaint had been made by a service users representative about laundry services which was noted in the service users care plan but not documented within the complaints records, neither was there any record of a response made. 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. Hatzfeld House Care Home DS0000028615.V333495.R01.S.doc Version 5.2 Page 18 Some staff have had training around Safeguarding Adults but others have a limited understanding in this important area. This leads to inconsistent knowledge and practice within the service. The service has a poor recruitment procedure with shortfalls in recording and process being evident. Staff are appointed and start working without references or other important documentation being received. [See standard 29] Hatzfeld House Care Home DS0000028615.V333495.R01.S.doc Version 5.2 Page 19 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): 19,20,21,22, 24, 25 and 26 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. 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 personalised. 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. Rooms viewed by the inspector were comfortable, clean and noted, to be very personalised. Hatzfeld House Care Home DS0000028615.V333495.R01.S.doc Version 5.2 Page 20 On the day of inspection there was no malodour observed. The home was observed to be, on the whole well maintained and kept clean. People who use the services are encouraged to personalise their bedrooms. The shared areas provide a choice of communal space with opportunities to meet relatives and friends in private. 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. 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. The home is comfortable, and has a programme to improve the decoration, fixtures and fittings. Occasionally there is slippage of timescales and maintenance tends to be reactive rather than proactive. The internal woodwork is looking tired and re- staining/varnishing is recommended. The bath hoist is also looking tired and requires attention to the enamel at the base. The metal external fire escape had evidence of moss residue, which should be cleaned to ensure they the staircase is safe to use in the event of an emergency. The home is well lit, clean and tidy and smells fresh. The management has a good infection control policy; they seek advice from external specialists, e.g. infection control, and encourage their own staff to work to the homes’ policy to reduce the risk of infection. Hatzfeld House Care Home DS0000028615.V333495.R01.S.doc Version 5.2 Page 21 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 poor. This judgement has been made using available evidence including a visit to this service. The numbers and skill mix of staff needs reviewing to ensure service users needs are fully met. Staff, have 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. Recruitment practices fail to fully protect service users. EVIDENCE: The manager is aware that there are some gaps in the training programme and plans to deal with this. The manager confirmed that there was not a training matrix in place. 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 and abuse awareness is covered within the induction; certificates were seen as evidence for this. Refresher training is needed for most staff however and some staff would benefit from additional training in Protection of Vulnerable Adults. Hatzfeld House Care Home DS0000028615.V333495.R01.S.doc Version 5.2 Page 22 Staff were able to confirm they had undertaken the training identified. Training is not provided to meet the specific needs of service users with Parkinson’s disease, diabetes, mental health needs or catheter care. Some staff were attending training in Dementia care on the day of the inspection. The service has a poor recruitment procedure with shortfalls in recording and process being evident. Four personal staff files were viewed. One staff member had been employed without references and full documentation in place therefore the requirement set at the previous two inspections is outstanding. The registered provider must take urgent action to ensure compliance. Failure to do so will result in enforcement action being taken. The manager reported that four staff members out of eighteen currently holds a level two National Vocational Qualification and four staff are currently working towards this. People using services are generally satisfied that the care they receive to meet their needs, but there are times when they may need to wait a short time for staff support and attention. The manager was involved with day-to-day care practice throughout the inspection in addition to the three care staff. It was evident that the care needs of service users are prioritised and regular toileting regimes practiced. Allocated time for activities is limited due to the dependency needs of service users and it is therefore recommended that the staffing levels are reviewed in respect of the dependency levels of service users and which allow the registered manager to undertake management responsibilities on a full time basis. Sufficient catering hours are provided but the hours provided for domestic and laundry combined fall short by five hours. 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 must be issued with a copy of the General Social Care Councils Code of Conduct Booklet. Hatzfeld House Care Home DS0000028615.V333495.R01.S.doc Version 5.2 Page 23 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 and 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The service is run and managed by a person who is qualified and in the best interests of those who reside in the home. Quality monitoring systems are in place. There was not sufficient evidence in place to support that service users financial systems are protected by the home. The health and safety of service users is not fully promoted and protected in respect of food safety practices and annual gas safety checks. EVIDENCE: Hatzfeld House Care Home DS0000028615.V333495.R01.S.doc Version 5.2 Page 24 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. It was not clear who was responsible for the overall management of the kitchen, the catering staff, the registered manager or the registered provider’s wife. There were a number of issues identified at the inspection in relation to food safety and which the Environmental Health officer had also identified at a recent visit and who had made requirements of which some had clearly not been met within the six - week timescale set. There was no evidence of temperature monitoring of frozen foods delivered to the home also there was poor stock rotation and food practices which exposed food to risk of contamination and placed service users at risk. Checks show that records are generally up to date although some gaps were found such as, the manager could non provide evidence of annual gas safety checks for this current year or for any previous checks. The manager reported that a five yearly electric safety certificate check had been undertaken and provided copy of an invoice for the work. A certificate for each is to be forwarded to the Commission. In one service users room, the carpet was frayed at the door entry, this had been reported by staff in October 2006 but had not been rectified. The manager was informed that immediate action must be taken to make the carpet safe and this was attended to immediately at the inspection. The Registered provider is required to ensure that repairs identified, which may place service users and staff at risk are attended to without delay and it is recommended that a system is implemented in the maintenance book, which prioritises work and carries any uncompleted repairs forward. 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. A sample of service users financial records could not be examined, as these were not available for inspection. Service users or their representatives remain responsible for their own finances and the Provider invoices for hairdressing etc as needed. 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. Hatzfeld House Care Home DS0000028615.V333495.R01.S.doc Version 5.2 Page 25 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 1 2 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 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 1 2 2 3 3 X 2 2 3 STAFFING Standard No Score 27 2 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 1 2 1 1 Hatzfeld House Care Home DS0000028615.V333495.R01.S.doc Version 5.2 Page 26 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 5 [2] Requirement Ensure all service users are issued with a copy of the Service user guide. Previous Timescale 23/01/07 NOT MET. This will ensure service users have the information they need about the home. 2. OP7 15 [2] 04/07/07 Ensure service users are fully involved in their care plans, the reviewing of these and give clear instructions for staff how the care needs are to be met for each identified need. Previous Timescale 23/01/07 NOT MET. This will ensure the needs of service users are fully met. 3 OP9 13 [2] 1, Staff must only sign the medication record after visibly observing that the service user has taken the medication. 2, Where prescriptions are handwritten on the medication record chart they must be Hatzfeld House Care Home DS0000028615.V333495.R01.S.doc Version 5.2 Page 27 Timescale for action 04/07/07 04/06/07 checked by two competent staff and signed as evidence of this. Residents may be at risk of not receiving their medicines as prescribed Inaccurate records mean that it is not possible to be sure whether residents have received their medicines as prescribed 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. Ensure the personal staff files contain the required evidence as specified in schedule 2 and 4 of the Regulations. Previous timescale 09/05 06 Not met. Outstanding. Failure to comply may result in Enforcement Action. Timescale 23/01/07 NOT MET. URGENT ACTION REQUIRED. Robust recruitment practices will ensure service users are not placed at risk from harm. Ensure all staff are issued with a copy of the General Social Care Councils Code of Conduct Booklet. [CSA section 62] This will ensure staff are informed as to their professional responsibilities and conduct. Ensure that records are completed appropriately and available for inspection at all times in relation to: Service users Contracts Hatzfeld House Care Home DS0000028615.V333495.R01.S.doc Version 5.2 Page 28 4 OP18 19 04/05/07 5 OP30 18[4] 04/07/07 6 OP37 17 04/07/07 Records of Complaints Service users finances Safety checks such as the Five Year Electrical Certificate And the Annual Gas safety check certificate. Records of the above are required by regulation for the protection of service users. Ensure in consultation with the Environmental Health Officer that food safety practices fully protect service users from risk. The Registered provider is required to ensure that all repairs identified, which may place service users and staff at risk are attended to without delay. This is needed to ensure the health and safety of service users and staff is fully promoted and protected. 7 OP38 13[3] 04/07/07 8 OP38 13[4] 04/06/07 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. 2. Refer to Standard OP1 OP3 Good Practice Recommendations Obtain a signature from service users or their representative for receipt of service user guide. Expand the care plan documentation to include a running history of falls and expand on the cultural and diversity needs of service users. Hatzfeld House Care Home DS0000028615.V333495.R01.S.doc Version 5.2 Page 29 3. 4. OP3 OP7 Use assessment tools for the assessment of nutritional screening. Provide a separate page for each 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. Include the provision of keys to lockable facilities with the risk assessment for bedroom door keys. Ensure the use of bedrails, is agreed by the service user or their representative and that they are fully informed of the potential risks of use of bedrails. 5 6 OP15 OP19 Where changes are made to the menu this should be documented and a record kept of the reason for this. Re-varnish the woodwork throughout the walkways and doors in the home. Make good the enamel on the base of the bath hoist. 7 OP24 8 OP27 Clean the moss from the fire escape. 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. The Registered Provider should undertake a review of the staffing levels based on the assessed needs of service users to ensure that: A regular programme of activities is provided, That the manager works full time supernumery and can undertake her management responsibilities on a full time day-to-day basis. That domestic and laundry hours are provided which equate to 2hrs per resident per week. Incorporate equality and diversity within the framework of services in the home and train staff accordingly. Provide regular refresher training for staff. Provide a detailed training plan/matrix 9. OP30 Hatzfeld House Care Home DS0000028615.V333495.R01.S.doc Version 5.2 Page 30 Provide staff with training in diabetes, Parkinson’s Disease, Mental Health difficulties and Catheter Care and ensure all staff has sufficient knowledge in abuse awareness. 10. 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. 7. 8. OP33 OP35 Set up service user/relative meetings. Implement a detailed policy and robust financial procedures in relation to service users personal monies. Supervision meetings should take place at least six times a year and include observations of practice and competency assessments for medication administration etc. Provide evidence in relation to recommendations from the Health and Safety audit in relation to fire exit doors etc have been carried out. 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. 9 10. OP36 OP38 11. OP38 Hatzfeld House Care Home DS0000028615.V333495.R01.S.doc Version 5.2 Page 31 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.V333495.R01.S.doc Version 5.2 Page 32 - 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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