Inspection on 07/12/05 for Hatzfeld House Care Home.

This inspection was carried out on 7th December 2005.

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.

Other inspections for this house

Hatzfeld House Care Home. 03/12/08

Hatzfeld House Care Home. 11/09/07

Hatzfeld House Care Home. 04/04/07

Hatzfeld House Care Home. 04/04/06

Hatzfeld House Care Home. 04/01/06

Hatzfeld House Care Home. 24/10/05

Hatzfeld House Care Home. 09/03/05

Hatzfeld House Care Home. 16/04/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Hatzfeld House Care Home 10b Mansfield Road Blidworth Nottinghamshire NG21 0PN Lead Inspector Jayne Hilton Unannounced Inspection 7th December 2005 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.V269831.R01.S.doc Version 5.0 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.V269831.R01.S.doc Version 5.0 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.V269831.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service Users shall be within category OP Date of last inspection 24th October 2005 Brief Description of the Service: Hatzfield 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.V269831.R01.S.doc Version 5.0 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 7th December 2005 at 10am. The unannounced visit, which was completed at 1.15pm, mainly focused on the requirements set at the previous inspection, four that were immediate in October 2005. Some remaining key standards were not assessed, as there was no access to some records and the time taken to work through the assessment with the manager. 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 visiting at the time of the inspection. Service users enjoyed a carol service provided by a group of local school children during the inspection. No service users were interviewed at this 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 most of 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. The acting manager did not have a copy of the National Minimum Standards or Care Home Regulations 2001 by which to work to so the inspector offered guidance wherever possible to ensure that the home is operating and working towards meeting both regulation and meeting National minimum Standards. Many of the previous requirements set were found, not to have been met, although some were not yet at the target date timescale. Some had been started but not completed. Four immediate requirements had been set at the last inspection 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. A further extension has been allowed in order for the provider to complete the work. Failure to comply with the notice may result in enforcement action being taken. There was no evidence of Provider visits as required by Regulation 26 or Quality Monitoring Systems in place. The Registered Provider must address this urgently. Failure to comply may result in the Providers Fitness being re-assessed. Hatzfeld House Care Home DS0000028615.V269831.R01.S.doc Version 5.0 Page 6 The Registered Provider had also not responded to the Immediate Requirement Notice by return post as requested, although the acting manager had responded by telephone and in writing, however this was not within the timescales. Please note action plans for requirements set within the draft are required within 28 days of receipt What the service does well: What has improved since the last inspection? Most of the requirements and recommendations set at the previous inspection are carried forward as not completed by this visit. Most have targets dates for 24/12/05. The acting manager reports that she is committed to improving the systems within the home. The acting manager provided evidence that risk assessments had been carried out. Hatzfeld House Care Home DS0000028615.V269831.R01.S.doc Version 5.0 Page 7 A visitor’s book was available and the complaints policy has been updated. Care plans are now noted to be stored securely and the acting manager is working to improve these. Care plans were now in place for the monitoring of pressure areas and mobility. The fire alarm and emergency lighting check records were available and satisfactory. A fire risk assessment had been commenced by the acting manager but not completed. The acting manager reported that outside consultants had been arranged to undertake appropriate Health and Safety Risk assessments for the premises but no date could be given for this. Work had commenced regarding the fitting of window restrictors but not yet fully completed. Food safety practices were improved and the acting manager reported that she and the staff had undertaken training in food hygiene. What they could do better: There was clearly some areas that require improvement regarding the overall management of the home, staff knowledge, direction for staff and supportive policies and procedures and an improved ethos towards the expectations of the Care Standards Act 2000, associated Regulations and National Minimum Standards, care planning and evaluation. There are several requirements still to e completed and some new ones set; many may compromise the health and safety of service users. 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.V269831.R01.S.doc Version 5.0 Page 8 The provision of social, cultural, religious and recreational interests and needs could be improved and service users helped to exercise more choice and control over their lives, particularly in relation to meal options. Evidence was not available to assess whether the service users receive a wholesome appealing balanced diet. 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. There are no quality monitoring systems in place and not all records that are required to be available for inspection were available. Service users health and safety may be compromised by, several issues in relation to safe practice and breach of regulation. Staff need to have training available to ensure service users are protected from abuse. The training provision needs to be improved to ensure the mandatory topics are covered sufficiently and for other assessed needs of service users. There was clearly some areas that require improvement regarding the overall management of the home, staff knowledge, direction for staff and supportive policies and procedures and an improved ethos towards the expectations of the Care Standards Act 2000, associated Regulations and National Minimum Standards, care planning and evaluation. There was also no evidence of the provider’s obligatory visits under Regulation 26. An immediate requirement is set in relation to this, particularly as the response to the requirements set from the previous two inspections appear not to have been fully and promptly acted upon and because of the serious risk implications to service users from the requirements identified. Failure to comply with this inspection report requirements, may result in the Registered Person being re-assessed in relation to their fitness as a provider. The inspector was unable to access records in respect of service users finances, staff personal records and training, maintenance and service records, complaints etc. Persons that have access to the records were not, once again available on the day of inspection. There was no evidence of fire drills or staff training in fire safety. A fire risk assessment had been commenced by the acting manager but not completed. The acting manager reported that outside consultants had been arranged to undertake appropriate Health and Safety Risk assessments for the premises but no date could be given for this. Hatzfeld House Care Home DS0000028615.V269831.R01.S.doc Version 5.0 Page 9 With this in consideration the inspector has agreed to extend the timescale set for the interim fire risk assessment to be completed within 7 days. [By 14/12/05] To avoid Enforcement Action this must be submitted to CSCI by this date. 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. 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.V269831.R01.S.doc Version 5.0 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.V269831.R01.S.doc Version 5.0 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 not all service users have a contract or 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.V269831.R01.S.doc Version 5.0 Page 12 A statement of purpose displayed in the home did 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. 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. As part of the admission process, it is good practice to include the issue of a service user guide with the terms and conditions or contract and for the service user or relative to sign that they have received a copy, which then can be kept in the service users personal information. The registration certificates were displayed clearly. There was a copy of the last inspection report on view; 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. To ensure the standard is fully addressed the room number is to be included (Standard 2.1). Not assessed at this inspection. Terms and conditions should be available for inspection for all service users residing in the home. 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] Hatzfeld House Care Home DS0000028615.V269831.R01.S.doc Version 5.0 Page 13 A sample of service users care plans were 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. There was also an application for placement at the home and some of the information overlaps or is missing. The documents need to be separated out/and/or consolidated to ensure that there clear assessment documentation that meets with Standard 3.3. Whilst there is some useful information, particularly regarding service users preferences, the document does not meet with the criteria for Standard 3 of the NMS. [Assessment and Care plans should reflect the topics listed i.e., foot care, mental health state and condition etc] plus any individual specific healthcare needs/conditions. The assessment and care plan format and process appears 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. Recorded evidence must be maintained by the home to support how the service users needs are assessed and to demonstrate the homes abilities to meet the needs of the service user (Standard 3.1, 3.2 and 3.3). There was no evidence of a missing person policy available or any risk assessments in service users personal information should they wander or go 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. At the previous inspection one of the service users case tracked appeared to have been admitted with a primary need of Dementia, for which the home is not registered to take people with these types of illness. [A registered person is in breach of the law if they admit service users with needs that the home is not registered to provide a service for.] The service user was re-assessed but did not return to the home after a hospital admission. The acting manager reported that she was now clearer about gaining more detailed information through the assessment process and will include a section in the assessment documentation regarding the service users primary need and home registration category. Hatzfeld House Care Home DS0000028615.V269831.R01.S.doc Version 5.0 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): 7-9 Service users health, personal and social needs are not 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, however the manager must address individual practices with staff. 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). 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 progress in the development of care plans and stated commitment to these being addressed by the target date of 24/12/05. The inspector agreed for 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.V269831.R01.S.doc Version 5.0 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 These issues were identified at the previous two inspections and the provider’s previous action plan stated that this would be met by 30th September 2005. Call alarms were noted to be responded to promptly. 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 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. Turn charts were evident for a service user who remains in bed. Two service users were reported to smoke and as the registered provider prohibits smoking in the home/on the premises. The acting manager had devised care plans for this issue. The homes policy for smoking should be amended to reflect current practices. 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. Hatzfeld House Care Home DS0000028615.V269831.R01.S.doc Version 5.0 Page 16 A medication policy was in place; however there was no policy for medication errors and this must be implemented by 14/12/05. There should be information for staff with the 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 not being taken and this must be actioned and documentation must be in place as evidence. The assessment of medicine management in the home is assessed as improved, however one service user who was in bed had not taken their medication and this had been left out. This confirmed that unsafe and unsatisfactory practice is still occasionally taking place and the acting manager must address this with individual staff members. 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.V269831.R01.S.doc Version 5.0 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): 12,14,15 The provision of social, cultural, religious and recreational interests and needs could be improved and service users helped to exercise more choice and control over their lives, particularly in relation to meal options. Evidence was not sufficient to assess whether the service users receive a wholesome appealing balanced diet. EVIDENCE: Standard 12 and Standard 14 were assessed at the previous inspection, due to time constraints at this visit the report and the recommendations in relation to the standard are carried forward to be assessed at the next visit. “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 need to provide a record of the activity provided and who participated. The service users and staff would benefit from the provision of an activities co-ordinator Hatzfeld House Care Home DS0000028615.V269831.R01.S.doc Version 5.0 Page 18 and some innovative and creative ideas should be introduced and based on the assessed social needs of service users.” Standard 14. “A service user was able to confirm that she could get up and go to bed when she wanted and that her independence, choice and autonomy were respected by staff working in the home. Bedrooms were observed, to be, personalised. The service users spoken with was not aware of being able to access her personal records in accordance with the data protection Act 1998”. There was no prepared menu available in the home and the inspector was unable to ascertain how meals were planned. A new menu board has been purchased and there were two \options written on the board. One was a vegetarian option, but it became apparent that the second option was only offered to a vegetarian service user and there was still no system in place to offer an informed choice of meal options for the main meal of the day, neither were there records of food taken by individuals as requested apart from tea time. Diabetic diets are provided for. A breakfast list is posted inside one of the kitchen cabinets, however there was no evidence that service users were given a choice of meal options and no evidence that service users were offered a balanced and nutritional diet/menu. Regulation 17, schedule 4 [13] states that “records must be kept of the food provided for service users in sufficient detail to enable any person inspecting the record to determine whether the diet is satisfactory, in relation to nutrition and otherwise, and of any special diets prepared for individual service user”. The inspector recommends a simple and practical way of achieving this along side a planned written menu with at least two options is to supply a page a day diary and to list the meal options chosen and taken by each service user, with the probed temperature record with the food item listed. This provides an instant daily record, which can be evaluated easily. Fridge and freezer temperatures can be recorded on the page also, which reduces several pieces of paperwork. There is a menu board displayed outside of the kitchen, this was blank on the day of the inspection and was reported to not now be in use. The inspector has therefore recommended individual menu be to be displayed on the dining room tables. In addition consideration is to be made on how service users can maximise their independence for example use of individual tureens / gravy boats and the option to have tea and coffee making facilities in service users individual rooms following a risk assessment. Hatzfeld House Care Home DS0000028615.V269831.R01.S.doc Version 5.0 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. The PIQ submitted by the manager reports no Adult Protection investigations for the home in the past twelve months. Hatzfeld House Care Home DS0000028615.V269831.R01.S.doc Version 5.0 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): 19,20,21,22,24,25,26 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 other issues identified for infection control, the safety and security of service users in relation to the drive and night lighting of this and the grounds. EVIDENCE: The home benefits from a recent extension providing four en-suite rooms, an assisted bathing facility and a lounge. The extension has been completed to a high specification. Hatzfeld House Care Home DS0000028615.V269831.R01.S.doc Version 5.0 Page 21 With the additional lounge, which has been included within the new extension the communal space meets the requirements set out within this standard. 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. There is however no security systems or night lighting for the exterior of the home and this is highly recommended. The entrance driveway was noted to have some pot - holes which result in an unlevel and therefore unsafe pathway for service users, staff and visitors. A Parker bath has been fitted within the new extension, offering an additional and valuable assisted bathing facility. In addition other toilet and washing facilities have been upgraded to meet the needs of the service users. 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). Ideally a signed declaration could be included in the terms and conditions document or in a care plan. The following was not assessed at this visit and therefore carried forward. One service user was noted to have special flooring in the bedroom; staff reported that this was provided prior to the service user moving in. There was no evidence in the care plan that the service user had agreed to the flooring or whether a carpet option had been offered on admission. During the tour of the accommodation the inspector evidenced a warm and comfortable environment. Hatzfeld House Care Home DS0000028615.V269831.R01.S.doc Version 5.0 Page 22 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). This is an outstanding requirement from the previous inspection and where failure to comply may result in enforcement action being taken. Evidence that risk assessments had been carried out were provided by the acting manager, and although these were not provided by staff at the previous visit, evidence was confirmed that they had been carried out on three occasions since February 05 by the acting manager and the handyperson and recommendations had been made for some to have covers. The acting manager reported that the Provider has organised for the priority areas to be measured but these have still not been fitted. Chairs were noted to be placed close to radiators in some bedrooms, and although the heating had been turned down on the radiators the bottom half of the radiator was still hot and would be a risk to a service user who may be in contact at this point. The inspector advised 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. The risk assessments are to be further reviewed in relation to the positioning of chairs and the provider must action the fitting of radiator covers promptly to ensure service users safety. Failure to complete this work by the revised timescale will result in Enforcement action being taken 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. On the day of inspection there was no malodour observed. The home was observed to be well maintained and kept clean. Towels and ‘emergency use’ continence aids are now stored in enclosed storage in bathrooms Hatzfeld House Care Home DS0000028615.V269831.R01.S.doc Version 5.0 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): 27, 28, 29, 30 Staffing levels meet requirements regarding numbers of service users, the training provision needs to be improved to ensure the mandatory topics are covered sufficiently and for other assessed needs of service users. EVIDENCE: The duty rota examined by the inspector recorded evidence of three care staff on duty throughout the day and two care staff during the night. It is recommended the duty rota reflect the shift to be worked as well as the hours. The levels of staff provided do meet with the staffing guidance minimum staffing levels, regarding numbers of service users. The manager reported that many of the team were currently undertaking NVQ’s and that an in house trainer provides Induction and foundation training. Information in the PIQ completed by the manager informs the inspector that 1 member has achieved NVQ2 and 1 is currently studying this. One is working toward level 4 and that staff undergo Skills for care 3 day induction training. A new staff member confirmed that she had completed her induction and that experienced staff were supporting her learning and getting used to the service users needs etc. Hatzfeld House Care Home DS0000028615.V269831.R01.S.doc Version 5.0 Page 24 There was training information available for staff on the notice board but no records available of what training staff have achieved, neither was there a training programme available to outline training needs of staff for the following twelve month period. 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. There was no evidence of food hygiene training although the manager confirmed that most staff had undertaken this. The acting manager confirmed that staff have undertaken first aid and training in infection control. Evidence of this must be provided at the next inspection. Standard 29 could not be assessed, as there was no staff available in the Porta-cabin. Arrangements must be made for the acting manager to be able to access the information that must be available for the next inspection. Hatzfeld House Care Home DS0000028615.V269831.R01.S.doc Version 5.0 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, 37,38 There are no quality monitoring systems in place and there is non-compliance of requirements set at the previous inspection, therefore this indicates the home is not being run in the best interests of service users. Not all records that are required to be available for inspection were available. Several issues in relation to safe practice and breach of regulation may compromise Service users health and safety. EVIDENCE: The newly employed acting manage is in the process of completing her Registered Managers Award with a view to take on the Registered Manager’s post. An application has been submitted for assessment of the fit person process. There was clearly some areas that require improvement regarding the overall management of the home, staff knowledge, direction for staff and supportive Hatzfeld House Care Home DS0000028615.V269831.R01.S.doc Version 5.0 Page 26 policies and procedures and an improved ethos towards the expectations of the Care Standards Act 2000, associated Regulations and National Minimum Standards, care planning and evaluation. There is a small office area in the conservatory. Some information that could not be located at the previous inspection, was seen, however not all records that should be available for inspection were accessible. 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 two inspections. There was also no evidence of the provider’s obligatory visits under Regulation 26. An immediate requirement is set in relation to this, particularly as the response to the requirements set from the previous two inspections appear not to have been fully and promptly acted upon and because of the serious risk implications to service users from the requirements identified. Failure to comply with this inspection report requirements, may result in the Registered Person being re-assessed in relation to their fitness as a provider. The inspector was unable to access records in respect of service users finances, staff personal records and training, maintenance and service records, complaints etc. Persons that have access to the records were not, once again available on the day of inspection. A visitor’s book was available. Care plans are now noted to be stored securely The fire alarm and emergency lighting check records were available and satisfactory. There was no evidence of fire drills or staff training in fire safety. A fire risk assessment had been commenced by the acting manager but not completed. The acting manager reported that outside consultants had been arranged to undertake appropriate Health and Safety Risk assessments for the premises but no date could be given for this. With this in consideration the inspector has agreed to extend the timescale set for the interim fire risk assessment to be completed within 7 days. [By 14/12/05] To avoid Enforcement Action this must be submitted to CSCI by this date. In addition the inspector has recommended the fire door situated on the first floor to be fitted with an alarm (Standard 38.2). Hatzfeld House Care Home DS0000028615.V269831.R01.S.doc Version 5.0 Page 27 At the previous inspection staff reported that they all have regular training in manual handling and most have first aid and health and safety training. As stated previously, records must be provided as required by regulation to support this. 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. Hatzfeld House Care Home DS0000028615.V269831.R01.S.doc Version 5.0 Page 28 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 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 1 2 3 3 3 2 2 1 2 STAFFING Standard No Score 27 3 28 2 29 X 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 1 X X X 1 1 Hatzfeld House Care Home DS0000028615.V269831.R01.S.doc Version 5.0 Page 29 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 Timescale for action 24/12/05 2 OP3 14,15 3 OP7 12,13,14, 15 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. Previous Timescale Not met 7/11/05. 24/12/05 All service users are to be fully assessed prior to admission and as on ongoing evaluation process to ensure the home is able to meet the needs of the service user and that they meet the criteria of the registration category and ensure service users are provided with written confirmation that the home can meet their needs within the limit of the homes registration categories. 24/12/05 Develop the care plans to: • Ensure service users who are at risk of wandering have the risk to their safety adequately assessed and documented in a care plan. Ensure care plans clearly define actions to be taken by Version 5.0 • Hatzfeld House Care Home DS0000028615.V269831.R01.S.doc Page 30 staff to address individual service users needs • To include service users and or their representatives signature with the written plan of care Ensure evidence is provided of appropriate evaluation and review of care plans and consultation with service user in this process. Ensure all specific needs and identified risks are documented as part of the individuals care plan, in relation to smoking, walking to end of the driveway, use of monitor alarms, • • 4 OP9 12, 16 Medicines Act Ensure evidence is documented regarding assessment of the nutritional needs of service users, tissue viability and history and risk of falls. Medication must not be left unattended. Ensure the storage temperature of medication is taken and documented Ensure a policy is provided for the event of medication errors. 24/12/05 5 OP15 16,17 Ensure evidence is provided that the food provided meets with regulatory requirements: Records must be kept of the food provided for service users in sufficient detail to enable any person inspecting the record to determine whether the diet is satisfactory, in relation to nutrition and otherwise, and of any special diets prepared for individual service user”. 24/12/05 6 OP19 23 Ensure the home the external grounds are safe for use by service users and appropriately DS0000028615.V269831.R01.S.doc 24/12/05 Hatzfeld House Care Home Version 5.0 Page 31 maintained. • Ensure adequate night lighting is provided to the outdoor environment and driveway. 7 OP24 12, [4][a] 8 OP25 13,16,23 Ensure the driveway is repaired and made safe for service users and visitors to walk on. 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 Radiators identified, as high priority risk must be fitted with a suitable guard. To fit window retainers to all windows-Complete outstanding work by Ensure all staff undertakes mandatory training and that evidence of this is available for inspection. Provide training for all care staff in, first aid, manual handling, infection control, health and safety. 24/12/05 24/12/05 9 10 OP25 OP30 13,16,23 18 24/12/05 24/12/05 11 12 OP33 *RQN 24, 26 To implement a system to monitor the quality of care provided. The Registered Provider must undertake visits and reports of the home as required by regulation 26. An immediate requirement is made for this to be carried out and submitted to CSCI by 14/12/05 Ensure records required by regulation are available for inspection at all times. [The Acting Manager must have access to staff personal files.] 24/12/05 14/12/05 13 OP37 17,37 07/12/05 Hatzfeld House Care Home DS0000028615.V269831.R01.S.doc Version 5.0 Page 32 The Registered Person must ensure that CSCI are notified upon death of a service user and other incidents as specified by Regulation 37 14 15 OP38 OP38 12, 16, 23 To submit the completed Fire risk assessment for the home to CSCI. 16,23 Seek advice from the Environmental Health officer in relation to the regulation of hot water outlets and systems to prevent legionella 24/12/05 24/12/05 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 Refer to Standard OP1 OP4 OP8 OP8 OP9 OP9 OP10 OP12 OP12 Good Practice Recommendations Obtain a signature from service users or their representative for receipt of service user guide Provide an accessible missing person protocol for staff. Use assessment tools for assessment of risk of pressure areas, nutritional screening. 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 Document the activities provided on a daily basis and who participated Consider providing an activities co-ordinator and reviewing the activities provided to meet the identified social needs of service users. To provide up to date information about the activities DS0000028615.V269831.R01.S.doc Version 5.0 Page 33 Hatzfeld House Care Home 10 11 12 13 OP18 OP27 OP30 OP31 provided by the home and to circulate to all service users in formats suited to their capacity Provide training for staff for adult protection. Ensure the duty rota reflects: Shift to be worked Provide an annual training programme for staff. Improve the overall management and administration in the home and increase staff knowledge and skills in conjunction with the ethos of the Care Standards Act 2000, The Care Home Regulations 2001 and the associated National Minimum Standards. Obtain a copy of the Care Home Regulations and National Minimum Standards. Delegate the responsibility for ensuring adequate first aid supplies and stocks to specific staff members. 14 OP38 Hatzfeld House Care Home DS0000028615.V269831.R01.S.doc Version 5.0 Page 34 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.V269831.R01.S.doc Version 5.0 Page 35 - 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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