CARE HOMES FOR OLDER PEOPLE
Hatzfeld House Care Home 10b Mansfield Road Blidworth Nottinghamshire NG21 0PN Lead Inspector
Jayne Hilton Unannounced Inspection 4th January 2006 10:00 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.V275895.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.V275895.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 Mr Roger Willis 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.V275895.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 7th December 2005 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 spaces. The level of adaptation is sufficient for meeting the needs of current service users. Hatzfeld House Care Home DS0000028615.V275895.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was carried out by, Jayne Hilton on Wednesday 4th January 2006 at 10am. The unannounced visit, which was completed at 2.30pm, mainly focused on the requirements set at the previous inspection, two of those were immediate. Some remaining key standards were finally assessed, as records were made available The Inspector spent a large amount of time to work through the assessment with the acting manager and to explain the expectations of the Care Standards Act 2000, The Care Home Regulations 2001 and The National Minimum Standards. The methodology used 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. The management of medication was partly assessed and the systems in place for health and safety, food and nutrition. There were no relatives interviewed and no service users were interviewed at this inspection due to the time taken for the other areas of inspection. Staff were spoken to about various issues throughout the inspection. The registered manager/provider has recently employed a new acting manager and an application, has been received by the Commission for Tracey Graham, which will undergo assessment in the near future. The acting manager was present for the inspection and the inspector was able to work through the requirements set and provide guidance to the acting manager who demonstrated a commitment to ensuring that the home is brought up to date with current legislation and practices. Many of the previous requirements set were in process or found, to have been met. Four immediate requirements had been set at the inspection on 24th October 2005 as these posed a serious risk for service users. Because there was evidence at this inspection that work had commenced to comply but not all of the work had been completed and the registered provider had commissioned a professional health and safety audit carried out on 22nd December 2005, the inspector assessed the immediate requirements set as now complied with. There was evidence that progress had been made in the short timescales and that the acting manager was working with the inspector to ensure that the home was being managed and run in line with the expectations of the Regulations and Standards for care home provision. Two Immediate requirements set at the inspection on 7th December 2005 have been complied with fully. The Registered Provider had responded to the Immediate Requirement Notice by return post as requested.
Hatzfeld House Care Home DS0000028615.V275895.R01.S.doc Version 5.1 Page 6 Three immediate requirements were set at this inspection. Please note action plans for requirements set within the draft inspection report are required within 28 days of receipt What the service does well: What has improved since the last inspection?
Many of the requirements and recommendations set at the previous inspection are not fully completed by this visit. The Inspector acknowledged that work is progressing and there has been a fair amount of issues to address alongside the Christmas and New Year festivities to arrange. Some target dates for
Hatzfeld House Care Home DS0000028615.V275895.R01.S.doc Version 5.1 Page 7 24/12/05 have not been met. The acting manager reports that she is committed to improving the systems within the home and working with the inspector to improve the standards within the home. A fire risk assessment had been completed. The acting manager reported that outside consultants had carried out a full safety audit of the premises on 22nd December 2005. The consultant is to further develop the fire risk assessment. Work had commenced regarding the fitting of window restrictors but not yet fully completed. Food safety practices were improved and there was now evidence that service users were being offered a second main meal option and records were kept of this. Evidence was provided for the provider’s obligations under Regulation 26. Records that had not been previously available for inspection, were seen at this inspection. Some progress has been made in bringing the assessment and care plan documentation to current standards. The acting manager has now a copy of The Care Home Regulations and Standards in which to work from. What they could do better: Prospective service users and existing service users do not have 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 improved to ensure all service users needs are fully met. Service users health, personal and social needs are not fully set out in the present system and much work is required to improve care alongside a system for monitoring and evaluating the healthcare needs of service users which also need to be improved to ensure that risks are appropriately assessed and minimised. The current system for the management of medication needs further attention to meet both NMS and Regulation.
Hatzfeld House Care Home DS0000028615.V275895.R01.S.doc Version 5.1 Page 8 There are 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. 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 was no evidence of quality monitoring systems in effect at the home. There was no evidence of service survey’s being carried out. This has been outstanding from the previous three inspections. The acting manager and staff were advised to carry one out promptly and to consider the subject of food, nutrition and menus to be the topic. 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. In addition the inspector has recommended the fire door situated on the first floor to be fitted with an alarm (Standard 38.2). There was no evidence of water outlet temperatures or 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. Immediate requirements are set for the following: 1. Newly employed staff must not be permitted to commence work duties prior to the receipt of a satisfactory POVA check, a satisfactory Criminal Records Disclosure and two satisfactory written references. Regulation 7,9,19. Immediate. In emergencies staff may be permitted to work with the receipt of a satisfactory POVA First check but must be appropriately supervised at all times until the criminal records disclosure is received. 2. Eight radiators identified as high risk to service users on 22nd December 2005, must be fitted with covers by 13/1/06 Regulation 12, 13, 16, 23. Hatzfeld House Care Home DS0000028615.V275895.R01.S.doc Version 5.1 Page 9 3. The window in the staff toilet on the first floor was found to be unrestrained and posed a risk to service users as the room is accessible by them. The room must be kept locked until a safety restrictor is fitted. Regulation 12, 13, 16, 23. Immediate 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. Hatzfeld House Care Home DS0000028615.V275895.R01.S.doc Version 5.1 Page 10 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.V275895.R01.S.doc Version 5.1 Page 11 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 Prospective service users and existing service users do not have up to date information they need to make an informed choice about where they live and although contracts are provided service users do not have written confirmation that the home can meet their assessed needs. The process for assessment, review and evaluation of changing needs of service users needs to be improved to ensure all service users needs are fully met. EVIDENCE: Hatzfeld House Care Home DS0000028615.V275895.R01.S.doc Version 5.1 Page 12 At the inspection on 7th December 2005 a statement of purpose displayed in the home was found, not meet the requirements of standard 1 and regulation 4. The acting manager informed the inspector that the information regarding complaints had been updated to CSCI [Commission for Social care Inspection] from NCSC. There is an outstanding requirement regarding other information not included in the document and needs to state the experience and qualifications of the Registered Provider / Registered Manager, to reflect the number of rooms provided and also to reflect the room sizes. The acting manager reported that she had amended the documentation in the foyer. On examination of this folder after the manager had left, it became apparent that the documentation in the foyer did not meet with the requirements for the Statement of Purpose as specified in Schedule 1 of the Care home Regulations. There 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 a service user 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. A requirement was made that an up to date copy of the documents MUST be submitted to CSCI by 24/12/05 to avoid Enforcement Action as the previous timescale for action [31st July 2005] and 7/11/05 have not been met. The timescale had not been met and the acting manager had not realised the information that was required by schedule 1 of the Regulations. The Inspector has fully explained the topics required to the acting manager and agreed to allow the acting manager further time for the document to be completed. [This consideration has been made in relation to the other priority issues that need to be addressed and because of the short timescales set originally for the work to be carried out over the Christmas period. However the inspector has been more than reasonable in consideration and in giving input to the acting manager, the inspector has extended the timescale and expects the document should be completed by the end of January 2006. 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. Hatzfeld House Care Home DS0000028615.V275895.R01.S.doc Version 5.1 Page 13 There was a copy of the last inspection report on view; however there was no information viewed regarding how this could be accessed by service users or relatives. [A requisite of the service user guide regulation] The Terms and Conditions pr-forma was evidenced. Evidence was provided of terms and conditions for a newly admitted service user. The regulation also requires that the registered provider inform the service user in writing that the home can meet their needs. [Regulation 14[1][d][Not Met] A sample of service users care plans was examined as part of the assessment process for the requirements set at the previous inspection. The Acting manager was advised that extended community care assessments should be kept within the care plan file. The acting manager or the deputy visit prospective service users to carry out a pre – assessment, however there was some confusion as to what documentation is used for this. The Prospective Resident Assessment Portfolio was shown to the inspector and this document meets with standard 3 of the NMS apart from there is no section for history of falls and the section for emotional support should be expanded to include the mental health needs of service users. The assessment and care plan format and process appears still somewhat disjointed and staff did not appear to use these as working documents. A review of the system is highly recommended to improve both the documentation and practice and ensure that service users needs are met. It is recommended that any of the old type assessments are destroyed to ensure only copies of the Prospective Resident Assessment Portfolio be used once amended. There was still no evidence of a missing person policy available but work had progressed on risk assessments in service users personal information should they wander or goes missing. The acting 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 policy should be in place and an identification sheet for each service user should be devised as part of this. Hatzfeld House Care Home DS0000028615.V275895.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- 10 Service users health, personal and social needs are not quite fully set out in the present system and needs to be improved. 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 improved but further work is required in relation to medicine policies. EVIDENCE: Care plans viewed provided a brief overview of individual service users needs however the content does not specify actions to be taken by staff to meet individual service users needs (Standard 7.2) and need expanding to contain more detail and cover the individual specific needs of service users. Review dates were recorded monthly but there was no evidence of evaluation and review of service users changing needs or reassessment of needs. The acting manager has made some further progress in the development of care plans although these had not been completely addressed by the target date of 24/12/05. The acting manager had updated the agreed three care plans to be completed by this date and for the others to e updated as an ongoing process.
Hatzfeld House Care Home DS0000028615.V275895.R01.S.doc Version 5.1 Page 15 The inspector was unable to evidence service users involvement with the care planning process. The acting manager is now clear about how to involve service users and/or their representatives and to evidence this. A newly admitted service user had not agreed to his care plan despite having the assessed ability to do so. The acting manager reported that she was allowing the service user to settle and would be gaining the service users signature later in the week. 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. The acting manager reported how staff dealt with concerns about service users nutritional needs, however there was no evidence of nutritional assessments in service users care plans. General risk assessments were present and the manager has completed mobility information. There was 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. Service users with pressure sores had care plans in place. Specialist equipment was observed, to be provided for those, requiring pressure area prevention. There were no assessments in place for tissue viability and this is recommended. Also the care plans should identify that the district nurse is coordinating the service users treatment. The acting manager reported that she was trying to engage the district nurse in obtaining nutritional\and skin integrity assessment tools and to provide training for staff in how to use these. Continence appeared to be well managed. Service users presented well cared for and appropriately dressed. The inspector observed staff using hoists to assist service users with mobility. A local community pharmacist provides a blister pack system for medication. The inspector directly observed a care worker dispensing and administering medication. The practice of pre-potting medication has now ceased and the acting manager has started periodic competency assessments. These however need to be documented. A medication policy was in place; however there was no policy for medication errors and this had not been implemented by 14/12/05.This requirement is outstanding and must be complied with by the new timescale to avoid enforcement action. There should be information for staff with the
Hatzfeld House Care Home DS0000028615.V275895.R01.S.doc Version 5.1 Page 16 Medication Records for this and should include that medication errors must be reported under regulation 37 to CSCI. The policy needs to inform staff of the need to keep medication after the death of a service user for seven days in case of a Coroner enquiry. The acting manager confirmed that staff had received training in medication management via the community pharmacist and by distance learning training but evidence of this was not available for inspection. 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 storage of medication was assessed at this inspection and very limited and an alternative source was recommended to be considered (Standard 9.4). The inspector recommends that a suitable medication trolley be used for storing and dispensing from and that the storage room be cleared and tidied. Storage temperatures were being actioned on the day of the inspection. The assessment of medicine management in the home is assessed as improved. Advice was provided to the acting manager 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. (Standard 10.1). To ensure service users privacy in bedrooms, nets or blinds are to be offered and evidence should be recorded within the care plan. Indirect observations evidenced that staff were interacting appropriately with service users. Hatzfeld House Care Home DS0000028615.V275895.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 are helped to exercise choice and control over their lives and can maintain relationships with friends and family. Service users receive a wholesome appealing balanced diet. EVIDENCE: The inspector examined recorded evidence of documentation of individual service users personal and social history. 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. The service users and staff would 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. The assessment and care plans and discussion with the acting manager evidenced that service users were encouraged to be as independent as possible and that, choice and autonomy were respected by staff working in the
Hatzfeld House Care Home DS0000028615.V275895.R01.S.doc Version 5.1 Page 18 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. There was now a prepared menu available in the home. A new menu board has been purchased and there were two options written on the board and evidence that service users were given an informed choice of meal options and a record was being kept of this. Diabetic diets are provided for. Hatzfeld House Care Home DS0000028615.V275895.R01.S.doc Version 5.1 Page 19 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): 18 Staff although aware of how to report poor practice need to have training available to ensure service users are protected from abuse. EVIDENCE: The policy for adult protection was available at this inspection but this was not fully assessed due to time constraints. There was no evidence of training provided for adult protection [although it is covered as part of the initial induction]. The PIQ submitted by the manager reports no Adult Protection investigations for the home in the past twelve months. Hatzfeld House Care Home DS0000028615.V275895.R01.S.doc Version 5.1 Page 20 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): 19,20,22,23,24,25,26 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, however there are outstanding requirements in relation to surface temperatures of radiators, the provision of window restrictors, door locks to bedrooms and the safety and security of service users in relation to the drive and night lighting of this and the grounds. 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 of a high standard. There is an enclosed garden accessible to service users that is 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 and this is highly recommended.
Hatzfeld House Care Home DS0000028615.V275895.R01.S.doc Version 5.1 Page 21 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 high number of rooms noted, to be very personalised. Locks on doors have been fitted to most service users rooms but on discussion with the acting manager it was reported that service users do have the opportunity to have a key, but there was no evidence within care plans of risk assessments where service users are not able or do not wish to have a bedroom door key. (Standard 24.6). A newly admitted service user since the last inspection had not been offered the opportunity to have a key despite being assessed as able to do so. The inspector advised that a section for key holding should be included in the assessment documentation, to ensure this is not missed. The Acting manager reported that she is to address this and the privacy issue together. During the tour of the accommodation the inspector evidenced a warm and comfortable environment. However several rooms were found to have radiators that were exceedingly hot to the touch and not adequately guarded. An immediate requirement was issued by the inspector at the previous inspection for a risk assessment to be completed to establish service users at risk of being burnt. Areas identified must be fitted with a suitable guard (Standard 25.5). The acting manager reported that the provider had arranged for a health and safety audit of the premises and had demonstrated a commitment to the provision of covers and that these had been measured for. The requirement previously set is assessed as addressed with as the provider had demonstrated a commitment to action in this respect. However the Health and Safety Audit highlighted that eight radiators posed a risk to service users health and safety and therefore an immediate requirement is set from this inspection to fit covers by 13th January 2006 The inspector advised at the previous inspection for the acting 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 not been actioned. Work has been progressed regarding fitting windows on the ground floor with a suitable retainer. An immediate requirement was issued for these windows to be fitted with a retainer (Standard 25.1). Most were observed to have been completed, however the lounge areas and conservatory are still outstanding and must be completed by 30th March 2006.
Hatzfeld House Care Home DS0000028615.V275895.R01.S.doc Version 5.1 Page 22 The window in the staff toilet on the first floor and which is accessible by service users is not fitted with a safety restraint and therefore an immediate requirement was set for the room to be locked until the window restrictor can be fitted. On the day of inspection there was no malodour observed. The home was observed to be well maintained and kept clean. Hatzfeld House Care Home DS0000028615.V275895.R01.S.doc Version 5.1 Page 23 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): 29,30 Service users safety may be compromised by the breach in recruitment policy and practices. Staff are trained and competent to do their jobs but further evidence is needed to ensure this is fully up to date for all staff employed by the home. EVIDENCE: There was some training information available but there was not a training programme available to outline training needs of staff for the following twelve month period. There was evidence of manual handling training, essential first aid, food hygiene, infection control; skills for care induction and foundation. The manager reported that health and safety 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 only verbal evidence that one 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 is to be booked for health and safety and fire safety after further discussions with the health and safety consultants. Hatzfeld House Care Home DS0000028615.V275895.R01.S.doc Version 5.1 Page 24 Arrangements have been made for the acting manager to be able to access the information that must be available for inspection. A sample of six staff personal files were examined, four were found to be in breach in relation to recruitment checks as the necessary checks had not been carried out prior to the staff members commencing their duties with the home. Newly employed staff must not be permitted to commence work duties prior to the receipt of a satisfactory POVA check, a satisfactory Criminal Records Disclosure and two satisfactory written references. Regulation 7,9,19. Immediate. In emergencies staff may be permitted to work with the receipt of a satisfactory POVA First check but must be appropriately supervised at all times until the criminal records disclosure is received. The staff personal files were also missing the required documentation in relation to schedules 2 and 4 of the Regulations. Hatzfeld House Care Home DS0000028615.V275895.R01.S.doc Version 5.1 Page 25 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): 33,35,36,38 There are no quality monitoring systems in place, no formal supervision of staff and several issues in relation to safe practice and breach of regulation may compromise Service users health and safety. Service users financial systems are generally protected by the home, however improved policies and procedures are needed to ensure these are robust. EVIDENCE: There was no evidence of quality monitoring systems in effect at the home. There was no evidence of service survey’s being carried out. This has been outstanding from the previous three inspections. The acting 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. These should be maintained monthly.
Hatzfeld House Care Home DS0000028615.V275895.R01.S.doc Version 5.1 Page 26 A sample of service users financial records were examined and found to be satisfactory. 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. Formal supervision is not in place and this needs to be implemented as specified in Standard 36.1-36.5 and Regulation 18 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 inspection. The acting manager promised to provide evidence of this by the due target date. There was no evidence of water outlet temperatures or 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. Outstanding at this inspection. Two new first aid boxes have been purchased. Hatzfeld House Care Home DS0000028615.V275895.R01.S.doc Version 5.1 Page 27 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 1 2 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 2 3 X 3 3 2 1 3 STAFFING Standard No Score 27 X 28 X 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 1 X 2 1 3 2 Hatzfeld House Care Home DS0000028615.V275895.R01.S.doc Version 5.1 Page 28 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 Requirement An up to date Statement of Purpose and Service User Guide must be provided for the home that meets with the requirements of Schedule 1. This must be submitted to CSCI by 24/12/05. Not met Previous Timescale Not met 7/11/05. Outstanding. Ensure service users are provided with written confirmation that the home can meet their assessed needs. Ensure a policy is provided for the event of medication errors. Outstanding. Ensure medication policies are in place which meet with the Medicines Act Ensure the home the external grounds are safe for use by service users and appropriately maintained. Ensure adequate night lighting is provided to the outdoor environment and driveway. Previous timescale set 24/12/05
Hatzfeld House Care Home DS0000028615.V275895.R01.S.doc Version 5.1 Page 29 Timescale for action 30/01/06 2 OP2 14 30/03/06 3 OP9 12,13,16 03/02/06 4 5 OP9 OP19 12,13,16 23 30/03/06 30/03/06 not met but work is underway. 6 OP24 12[4][a] To ensure evidence that service users are provided with the option to have a key to their room and lockable facilities unless their risk assessment suggests otherwise. Previous timescale not met 24/12/05. Outstanding. Ensure the eight radiators identified, as a high priority risk are fitted with a suitable guard. Immediate by 13/1/06 Ensure the staff toilet is not accessible for service users until a suitable safety restrainer is put in place on the window. Newly employed staff must not be permitted to commence work duties prior to the receipt of a satisfactory POVA check, a satisfactory Criminal Records Disclosure and two satisfactory written references. Regulation 7,9,19. Immediate. In emergencies staff may be permitted to work with the receipt of a satisfactory POVA First check but must be appropriately supervised at all times until the criminal records disclosure is received. Ensure the personal staff files contain the required evidence as specified in schedule 2 and 4 of the Regulations Ensure all staff undertakes mandatory training and that evidence of this is available for inspection. Provide training for all care staff in, health and safety and fire safety. Outstanding. 12 OP33 25 To implement a system to monitor the quality of care
DS0000028615.V275895.R01.S.doc 30/03/06 7 OP25 12,13,16 13/01/06 8 OP25 16,23 04/01/06 9 OP29 7,9,19 04/01/06 10 OP29 7,9,17,19 30/03/06 11 OP30 18 30/01/06 30/03/06 Hatzfeld House Care Home Version 5.1 Page 30 provided. Previous timescale not met 24/12/05 Outstanding. 13 14 OP36 OP38 18 16,23 Implement formal supervision for 30/03/06 all staff Seek advice from the Environmental Health officer in relation to the regulation of hot water outlets and systems to prevent legionella. Previous timescale set not met. Outstanding. 30/01/06 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 3 4 5 6 7 8 9 10 11 Refer to Standard OP1 OP3 OP3 OP3 OP7 OP7 OP8 OP9 OP9 OP10 OP12 Good Practice Recommendations Obtain a signature from service users or their representative for receipt of service user guide Expand the assessment documentation to include history of falls and mental health needs. Provide an accessible missing person protocol for staff. Use assessment tools for assessment of risk of pressure areas, 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. Include a copy of the protocol for drug errors in the medication record file, which also prompts staff to report drug errors to CSCI To consider an alternative area for storage of medication and consider the use of an appropriate medicines trolley. To afford privacy provide service users with a choice to have nets or blinds fitted to their personal rooms Consider providing an activities co-ordinator and reviewing the activities provided to meet the identified social needs of service users.
DS0000028615.V275895.R01.S.doc Version 5.1 Page 31 Hatzfeld House Care Home 12 13 14 15 16 OP18 OP30 OP33 OP33 OP35 To provide up to date information about the activities Provide training for staff for adult protection. Provide an annual training programme for staff. Implement a service user/relative survey in relation to the change of menus 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. Delegate the responsibility for ensuring adequate first aid supplies and stocks to specific staff members. 14 OP38 Hatzfeld House Care Home DS0000028615.V275895.R01.S.doc Version 5.1 Page 32 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.V275895.R01.S.doc Version 5.1 Page 33 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
