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Inspection on 10/09/08 for Hazel Court Nursing Home

Also see our care home review for Hazel Court Nursing Home for more information

This inspection was carried out on 10th September 2008.

CSCI found this care home to be providing an Adequate service.

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

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

What the care home does well

Relatives of people living at the home say: "...the staff are always very caring and cheerful and attentive to the residents needs..." One professional involved with the service said: "...the staff seem to offer a good level of support...", whilst another said: "...manager is open to working closely with us and keen to improve the standards of care for the residents...".

What has improved since the last inspection?

At the previous inspection there had been seven areas where the home had to improve. The home has taken action on nearly all of these areas, which represents a positive response to the findings of previous inspections, and good developments to the service. In particular, the home has worked hard to develop the care planning and medication recording. Improvements have also been made to the environment to make it more stimulating for the residents.

What the care home could do better:

Areas where the home could be doing better are highlighted in the report and were discussed with the manager during the inspection. These include improvements to health and safety, environment and developing regular oneto-one staff supervision. Improvements also need to be made to ensure the CSCI is appropriately notified incidents affecting residents at the service.

CARE HOMES FOR OLDER PEOPLE Hazel Court Nursing Home Haydon Way Wandsworth Off St Johns Hill London SW11 1YF Lead Inspector Louise Phillips Key Unannounced Inspection 10:00a 10 September 2008 th 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 Hazel Court Nursing Home DS0000019096.V364743.R02.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Hazel Court Nursing Home DS0000019096.V364743.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hazel Court Nursing Home Address Haydon Way Wandsworth Off St Johns Hill London SW11 1YF 020 8870 6933 020 8871 0824 gaynor.hewitt@shaw.co.uk 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) Shaw healthcare (Homes) Limited Mohamed Haroon Dusmohamed Care Home 24 Category(ies) of Dementia (24) registration, with number of places Hazel Court Nursing Home DS0000019096.V364743.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing (CRH - N) to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Dementia - Code DE The maximum number of service users who can be accommodated is: 24 11th June 2007 Date of last inspection Brief Description of the Service: Hazel Court is a purpose built single storey care home for older people with dementia. It is situated off St Johns Hill in Battersea, approximately twenty minutes walk from Clapham Junction Station, and is also accessible by bus. The service is managed by Shaw Healthcare and the residents placements are funded by a Primary Care Trust. Hazel Court Nursing Home DS0000019096.V364743.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience adequate quality outcomes. This inspection took place over one day by one inspector. Time was spent talking to three staff and viewing paperwork. A tour of the premises was carried out and care records were inspected. Information has been gained from the inspection record for the home, the Annual Quality Assurance Assessment (AQAA), that the manager completed and surveys received from 5 residents, 13 staff, 6 relatives/ advocates of residents and 4 health/ social care professionals involved with the service. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Hazel Court Nursing Home DS0000019096.V364743.R02.S.doc Version 5.2 Page 6 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 Hazel Court Nursing Home DS0000019096.V364743.R02.S.doc Version 5.2 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 5 and 6 Quality in this outcome area is good. The residents are appropriately assessed prior to moving to the home, and they have the opportunity to visit the service to see if it the right place for them to move to. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Prospective residents to Hazel Court are appropriately assessed by the manager, deputy manager to ensure that the service is able to meet their needs. At the start of the assessment the service receives needs assessments and care plans from the local authority and from this the home carries out its own assessment. This information is then used to form the basis of the preadmission care plan for the resident during their move to the home. This covers a number of areas such as personal care, mental state, mobility, diet and communication. Hazel Court Nursing Home DS0000019096.V364743.R02.S.doc Version 5.2 Page 8 As part of the assessment process potential residents and their relatives are invited to visit the home to meet staff and residents and look at the service provided. Residents move in for an initial trial period of six weeks. Prior to the end of the six weeks a review meeting is held between the resident, their relative, social worker and manager of the home to review their stay and for the resident to decide if they want to stay. One relative commented about their experience of choosing Hazel Court for their relative to move to, saying: “…I liked the feel of Hazel Court, it gave good vibes…”. They further added that “…the management were very helpful, explained in full the procedure and introduced us to the nursing staff and carers who seemed genuinely concerned for the welfare of the residents…”. Intermediate care is not provided by the home. Hazel Court Nursing Home DS0000019096.V364743.R02.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. The residents’ needs are met through care planning that takes into account individual needs and preferences. Some improvements are needed to ensure that any risks to safety are planned for appropriately. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The responses to the surveys provide a valuable insight into the experience of residents living at Hazel Court, along with the observations of their relatives. Responses from residents indicate that they feel they get good care and support from the care staff. Relatives similarly say this, adding that they believe the home is able to meet the differing needs of the residents and that the care is delivered with kindness and with respect to their relatives privacy and dignity. Relatives say that staff keep them informed of important issues affecting their relative. One relative commented that they are “…always forthcoming to Hazel Court Nursing Home DS0000019096.V364743.R02.S.doc Version 5.2 Page 10 update us of (residents) health and wellbeing…”, whilst another said “…if relative hurts themselves they let you know straightaway…”. Feedback from staff reflect that they are very positive about their work, where they say that they work well as a team to meet the individual needs of each resident. In addition, feedback from health and social care professionals involved with the service is that they feel the home contact them when necessary, and that staff seek and utilise the advice that they give. One professional stated that the staff are “…very receptive to new ideas…always trying to improve the care of the residents…”, where another commented that “…the staff are professional and seek advice appropriately…”. Two other comments received from health and social care professionals involved with the service are: “…the standard of care has improved over the last twelve months dramatically…”, “…staff take advantage of learning opportunities when I visit…”. Residents, and their relatives feel that good medical support is provided, and records are kept of all visits by professionals such as the GP, social worker, chiropodist and dentist. However, one relative did say that “…hairdressing and chiropody could be more in evidence…”. The care plans for a number of residents were looked at during the inspection. The manager and staff said that a lot of work has been put into developing the care plans, following findings from the last inspection, and a Team Leader has the task of overseeing the care plans to ensure they are kept up-to-date. The new format now involves a risk assessment being carried out and then a care plan developed from this. It is more common that a care plan is developed and the risk assessment drawn from this, where an area of risk is identified, and this is a different approach to care planning that the service has adopted. The care plans contain individualised information such as communication needs, specific cultural or medical needs around eating and drinking, personal cleansing likes and dislikes, mobilising, and preferred times of sleeping. The care files are well-maintained, with records to demonstrate that appropriate assessments are carried out around the risks of pressure sores, nutrition, moving and handling and continence. However, the risk assessments were found to contain insufficient information in relation to some areas of need. An example of this is that for one resident who has a risk assessment for ‘social isolation’, the action plan to address this says ‘to formulate appropriate care plan’, further stating ‘ensure appropriate documentation completed to indicate effectiveness of intervention’. This is not an appropriate course of action for an identified area of risk, and it is not clear what care plan it relates to. Additionally, the weight chart for one resident shows that they were weighed on 19/8/08, where they were found to have lost 2.6kg since being weighed only three weeks previously. There was no risk assessment for this and no Hazel Court Nursing Home DS0000019096.V364743.R02.S.doc Version 5.2 Page 11 record in the daily notes. The care plans for this resident was evaluated on this date, though nothing added regarding this area of need. The new style of risk assessment and care planning must be kept under review and amendments made where necessary. Where a resident is unable to be involved in their care planning a consent form is signed by a relative to confirm their involvement. In some files these were seen to be dated in February/ March of this year, where these should be more regularly updated to show that relatives are involved in any changes to the care plan and any reviews. There is a good standard of record-keeping in the files, providing information about how each resident spends their day. However, staff some staff were using phrases such as: ‘toileted before lunch’, which should be discouraged and more appropriate terms used. The medication is overseen and audited by a team leader. These were seen to be well managed, with the medication room locked securely and medicine trolleys secured to the wall when not in use. The medication fridge temperature is checked daily. The controlled drug cupboard was locked and these are stored and recorded correctly. A sample of Medication Administration Records were checked and seen to have the ‘allergies’ sectioned completed, and no omission were observed on the charts. Hazel Court Nursing Home DS0000019096.V364743.R02.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. Residents have the opportunity to be involved in activities provided by enthusiastic staff. The meals cater to individual needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection the full-time activity co-ordinator no longer works at the service, and the manager said that they are in the process of recruiting a replacement. The activities are currently being provided by the care staff, and on the day of inspection staff were seen involving some residents in a game of domino’s and another was carrying out one-to-one nail care on residents. The home has installed a sensory room that was also seen being well used by residents, with the support of staff. The circular shape of the building allows residents to walk around freely, with no restrictions, and there is an enclosed garden that they can also access. Staff spoke about a recent ‘multicultural day’ that they had at the home, where they performed a show for the residents and brought in flags and food from their country of origin. Hazel Court Nursing Home DS0000019096.V364743.R02.S.doc Version 5.2 Page 13 The weekly activity timetable on display includes sessions on ‘what the papers say’, ‘hand and nail therapy’, one-to-one basketball, bingo and dominoes. Each resident has a care plan for activities which is individualised, where one states that the resident ‘prefers to be by self’, whereas another says the what group activities they like eg. sensory room, outings organised by home, and beauty sessions. The activity care plan for one resident says a one-to-one activity is a shave. The manager said that this is due to issues regarding the resident needing a shave, though agreed that this should be included in the care plan as a personal care task, not activity plan. The responses from a professionals who visit the service is that: “…the staff strive to engage with the clients and relatives much more than previously…”, and “…staff seek advice from friends and family of the residents about their interests…” A comment from one staff member is that they feel the activities could improve more “…so that residents feel more part of the local community…”. Relatives say that they are able to visit whenever they want, and are always warmly welcomed by the staff. There is a ‘relatives room’ where they are able to make themselves tea and coffee, and see their relative in private, should they wish. The manager said that the chef of the home is on extended maternity leave, but that an agency chef is in place during this period. The manager says that he ensures the chef is aware of individual residents needs regarding special diets, eg diabetes, soft food, whilst ensuring that a cultural mix of foods is offered throughout the week. Hazel Court Nursing Home DS0000019096.V364743.R02.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. There are systems in place to respond to and record complaints, though the record does not detail all complaints received. Staff receive training in abuse awareness, though appropriate actions regarding allegations received are not followed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service has a complaints procedure that is provided in the Service Users Guide and Statement of Purpose. Feedback from residents and their relatives is that they know how to make a complaint if there was something they were not happy about. Survey responses from staff demonstrated that they have a good awareness of how to deal with a complaint should they receive this, where they feedback that they would refer to the complaint procedure and direct the complainant to more senior staff in the service. There is a file held in the managers’ office specifically for the logging of complaints, along with records of actions taken and any correspondence relating to these. At the time of inspection the manager said that an complaint and allegation received by the home, involving a resident, was being investigated by social services. There was no record of this in the complaint file. The CSCI had not been informed of this, and must be informed of any event that affects the wellHazel Court Nursing Home DS0000019096.V364743.R02.S.doc Version 5.2 Page 15 being or safety of residents, without delay. A requirement has been made to address this. Training records demonstrate that the staff have received recent training in abuse awareness. Hazel Court Nursing Home DS0000019096.V364743.R02.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 25 and 26 Quality in this outcome area is good. The environment is welcoming and relaxed. The staff help create a calm atmosphere throughout the home. The décor and furnishings are good in most areas, though some improvements are needed to make the home more comfortable for the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Responses from relatives who responded to the surveys were very complaimentary about the environment, where comments received were: “…the manager has made noticeable efforts to improve the conditions in which residents spend a lot of their time eg. dining/ lounge area is homely and welcoming with new carpets, new pictures and display shelves providing much needed stimulation for the residents…”, Hazel Court Nursing Home DS0000019096.V364743.R02.S.doc Version 5.2 Page 17 “…they keep the home lovely…”, “…cleaning has improved greatly, as has the general environment…”, “…the cleaning staff are to be commended for all their hard work and pleasant manner in which they perform their duties…” One professional also said that the environment is much improved, though added that the service “…could improve the residents rooms…”. Accommodation is provided in single rooms, which have a hand basin and are situated near bathrooms and toilets. The home has two self-contained units, with their own kitchenettes and lounge areas. In the centre of the home is an enclosed garden with seating for residents. Staff say that there is appropriate equipment such as hoists and aids to enable them to do their work. Some said that they would like to see improvements made to the staff changing areas. Since the last inspection a number of developments have been made to the home, including the installation of a sensory room, new shower and pergola in the garden area. Seating has been rearranged in the lounge areas to encourage interaction between residents and photos of activities have been put on walls. Each residents bedroom has a memory/ life box attached to the outside of the door to help them identify which room is theirs. The manager said about further plans to improve the environment, particularly residents’ bedrooms and addressing the damp areas on the ceilings in the hallways. It was observed that a number of bathroom and toilet areas had exposed pipework, and these must be covered up to ensure the safety of the residents. Hazel Court Nursing Home DS0000019096.V364743.R02.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. The service provides training so that residents receive a good level of care, and recruitment procedures protect the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Hazel Court has a consistent staff team, some whom have worked at the home for a number of years, and who have a good understanding of the needs of the residents. Staff feedback that they are confident that the service they provide promotes the well-being and individuality of the residents. Staff say that they feel there is good teamwork amongst the staff, and that they support each other. A number of relatives were complimentary about the staff, with two saying that: “…I think the staff are marvellous people…they do so well in a very difficult job…” and “…they are considerate kind and very helpful…”. The home holds recruitment information on each member of staff. The staff files are well organised and contain relevant information such as proof of identification, correspondence relating to offer of job, Criminal Records Bureau check, two references and record of the interview of staff. Hazel Court Nursing Home DS0000019096.V364743.R02.S.doc Version 5.2 Page 19 All new staff receive an induction to the service which covers areas such as fire safety, first aid and communication. Staff who responded to the survey say that they received a good induction that prepared them well for their work, with one stating that “…I had a comprehensive induction…”. The manager said that following their induction, new staff are on a period of probation for the first six months of their employment and then it is compulsory that they are registered for their NVQ level 2 in care training. Staff said that they get enough training to support them in their work Training records indicate that staff have received recent training in moving and handling, fire safety, basic food hygiene and health and safety. A number of staff have achieved their NVQ level 2 in Care. The training records are on a computerised system that flags up where refresher training is needed for staff. The manager said that three staff are currently undertaking dementia care training, and that they receive training in wound care, continence and diabetes from the local PCT (Primary Care Trust). The manager also said that staff receive training in challenging behaviour, falls, promoting independence, communicating with people with dementia and person-centred planning. The manager should ensure that any training received by staff (in addition to that recorded on the computer) is recorded and certificates maintained to evidence this. Feedback from one healthcare professional is that they feel the staff should have more training and expertise in dealing with dementia care issues. Hazel Court Nursing Home DS0000019096.V364743.R02.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome area is good. The manager is developing the service for the benefit of the residents. Improvements are needed to ensure health and safety issues are addressed and that staff receive regular supervision in their work. This judgement has been made using available evidence including a visit to this service. EVIDENCE: In the survey sent to staff, they were asked to comment on what they feel the service does well. Some of the responses to these are: “…the home has been renewed…”, “…communication is good, there is no fear or intimidation from the management and everyone is encouraged to approach when need to…”, “…very helpful and receptive manager…” Hazel Court Nursing Home DS0000019096.V364743.R02.S.doc Version 5.2 Page 21 Feedback from healthcare professionals is that: “…manager has forged good support links and works closely to improve environment to offer appropriate activities…”, “…there has been a great improvement in how the home operates…”, “…the whole atmosphere is now very different with an improved service for the residents…”, One relative added that: “…the manager has done a lot of improvements which is good…”. The AQAA completed by the manager, and conversations with manager demonstrate that he has an understanding of what is needed to continue to improve the service for the benefit of the residents. He has a number of years experience in nursing, and is appropriately qualified for the role. Since the last inspection he has become registered with the CSCI as the Registered Manager for the service. The manager said that he has put a lot of work into restructuring the running of the home and giving staff ‘ownership’ of different areas of work, such as one overseeing care planning, one overseeing medication and others overseeing health and safety. Looking at quality assurance, the manager discussed a quality audit carried out by the organisation earlier this year, which they have used to develop the service. The record of the most recent visit carried out in accordance with Regulation 26 (of the Care Homes Regulations 2001) held at the home is dated May 2008, with the previous reports dated March 2008 and December 2007. The manager said he was not aware of a ‘Regulation 26 visit’ since May 2008. These findings do not demonstrate that the monthly visits are carried out, and a requirement has been made to address this. The manager said he has introduced quarterly relative meetings, but that these have not been well attended. He said that there are suggestion forms available for residents to complete, and that he operates an ‘open door’ policy if relatives wish to discuss any issues. The home holds a personal allowance for each resident that is funded by themselves, their family or through social services. This money is used for when a resident needs shopping or the hairdresser, etc. Records are maintained of all transactions. The management of the money is overseen by the administrator and manager of the service. The resident’s financial records are held on the computer in the administrators’ office. The administrator said that no-one in Shaw Healthcare is appointee for any resident, and that all the residents money goes into the same bank account. The Financial Accountant for the organisation was spoken to over the Hazel Court Nursing Home DS0000019096.V364743.R02.S.doc Version 5.2 Page 22 telephone during the inspection, where he stated that this account is noninterest bearing. The previous inspection required that staff receive supervision a minimum of six times a year, and that this must be recorded. The AQAA completed by the manager states: ‘supervision of staff takes place on a regular basis’, plus ‘we could improve more on supervision of staff by team leaders’. The manager said that the team leaders supervise the care workers, the deputy manager supervises the team leaders and he supervises the deputy manager. The computerised record of staff supervisions shows that staff do not receive regular supervision, and that this is inconsistent across the staff team. An example of this is that the records show that one member of staff last received supervision in March 2008, and prior to this in December 2007, October 2007 and September 2007. For another member of staff they had supervision in May 2008, with the last being in September 2007. The records provided show that not one member of staff has received the minimum six supervision sessions within the past year. This requirement has been restated. The manager said that some staff have been given the task of overseeing the health and safety checks and carrying out a monthly audit of these. The records for the monthly audit was checked, where records such as fridge temperatures, emergency light testing and most recent fire drills are audited. The form used for the audit asks for the dates of these last checks, whereas these have not been given, instead a tick has been put in the box, which does not give the information required. The service maintains records to demonstrate that appropriate health and safety checks are carried out on the fire system and equipment, portable appliance testing and gas safety. As highlighted above, the manager has restructured the running of the home, and given different tasks for staff to carry out, to give them ‘ownership’ of areas such as medication, care planning, supervision and health and safety. The findings from this inspection have highlighted that increased management is required to ensure that these are carried out correctly. It must also be emphasised that although areas have been delegated to other staff to oversee and carry out, as the Registered Manager for the service the responsibility for these ultimately lies with him. Hazel Court Nursing Home DS0000019096.V364743.R02.S.doc Version 5.2 Page 23 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 X X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 3 3 3 X X 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 3 Hazel Court Nursing Home DS0000019096.V364743.R02.S.doc Version 5.2 Page 24 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 OP7 Regulation 13(2)(c) Requirement The Registered Persons must ensure that risk assessments and robust risk management plans are in place for all areas of need identified to ensure that risks to residents are minimised The new style of risk assessment and care planning must be kept under review to ensure that risks to residents are minimised through clear assessment and planning. The Registered Persons must ensure that any change to resident’s needs are responded to promptly and appropriate action taken. The Registered Person must ensure that record of all complaints received is held at the home. The Registered Person shall give notice to the CSCI, without delay of any event in the care home which adversely affects the wellDS0000019096.V364743.R02.S.doc Timescale for action 30/09/08 2. OP7 13(5) & 14(2) 30/09/08 3. OP8 14(2) 30/09/08 4. OP16 17(2), Sch 4 (11) 37 10/09/08 5. OP18 10/09/08 Hazel Court Nursing Home Version 5.2 Page 25 being or safety of any resident. 6. OP19 23(2)(b) The Registered Persons must ensure that the home is of sound construction and kept in a good state of repair, and that all parts are kept clean and reasonably decorated. The Registered Persons must ensure that all exposed pipework around the home is boxed in to minimise risks to residents. 30/11/08 7. OP25 13(4)(a) 31/10/08 8. OP33 26 The Registered Provider must 30/09/08 ensure that visits in accordance with this Regulation are conducted at least once a month, and a record maintained for inspection. All staff must receive one-to-one supervision at least six times a year (pro-rata for part time staff) and this must be fully recorded. (PREVIOUS TIMESCALE NOT MET) 30/09/08 9. OP36 18(2)a 10. OP38 13(4)(c) & The Registered Persons must 23 demonstrate that the electrical installation at the service is satisfactory, to ensure the safety of the residents. 10/09/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations DS0000019096.V364743.R02.S.doc Version 5.2 Page 26 Hazel Court Nursing Home 1. Standard OP30 The manager should ensure that any training received by staff (in addition to that recorded on the computer) is recorded and certificates maintained to evidence this. Hazel Court Nursing Home DS0000019096.V364743.R02.S.doc Version 5.2 Page 27 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Hazel Court Nursing Home DS0000019096.V364743.R02.S.doc Version 5.2 Page 28 - 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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