Inspection on 21/06/06 for Hazel Court Nursing Home

This inspection was carried out on 21st June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Hazel Court Nursing Home 10/06/09

Hazel Court Nursing Home 10/09/08

Hazel Court Nursing Home 11/06/07

Hazel Court Nursing Home 07/02/07

Hazel Court Nursing Home 06/03/06

Hazel Court Nursing Home 12/04/05

Hazel Court Nursing Home 07/12/04

Hazel Court Nursing Home 06/05/04

Hazel Court Nursing Home 27/02/04

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

CARE HOMES FOR OLDER PEOPLE Hazel Court Nursing Home Haydon Way Wandsworth Off St Johns Hill London SW11 1YF Lead Inspector Janet Pitt Unannounced Inspection 21st and 26thJune 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Hazel Court Nursing Home DS0000019096.V300628.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Hazel Court Nursing Home DS0000019096.V300628.R01.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 02088710824 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 Limited Care Home with Nursing 24 Category(ies) of Dementia - over 65 years of age (24) registration, with number of places Hazel Court Nursing Home DS0000019096.V300628.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 06/03/2006 Brief Description of the Service: Hazel Court is a purpose built single storey care home. The home provides care for persons who have dementia. Hazel Court is situated off St Johns Hill in Battersea. It is approximately twenty minutes walk from Clapham Junction Station and is accessible by bus. All 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. There is a conservatory and a garden area. In the centre of the home is an enclosed courtyard with seating for service users. Hazel Court Nursing Home DS0000019096.V300628.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A regulation inspector and a pharmacy inspector undertook this unannounced inspection. The site visit lasted a total of eight hours. Ten surveys were sent to each of the following groups, residents, relatives and staff. Two staff, four relatives and six residents surveys were received and comments from these have been used to inform the inspection process. Care documentation and staff records were examined and a brief tour of the premises was undertaken. What the service does well: What has improved since the last inspection? Mealtimes and choice of food has improved since the previous inspection, but some more work is required to make sure the meal is pleasant and sociable. Staff are taking care to make sure that the food served is consistent with the published menu, however they need to make sure that the experience is pleasant for the resident. (see under the section Daily Life and Social Activities for further comments). There is now a planned activities programme in place, which is a good basis for developing further, to make sure that residents’ interests are maintained and the programme of activities is varied. Hazel Court Nursing Home DS0000019096.V300628.R01.S.doc Version 5.2 Page 6 Improvement has been made in making sure that fire checks and water checks are carried out routinely and recorded. Improvement has been made in the recording and auditing of medication although the auditing of medication had not picked up some incidents. The home needs to improve the monitoring, detection and reporting on medication errors and the fridge temperature to ensure that the health and welfare of residents is protected. What they could do better: Comments from relatives’ surveys stated that activities are an area for improvement; this was also highlighted in staff surveys. As mentioned above now that an activities programme has been established within Hazel Court, this must be built on to provide a range of activities. Mealtimes have improved, but this must be consistent. One resident got up from the table three times during lunch and each time was directed back to the table to eat. Staff must show more awareness of nutrition for persons with dementia and consider high calorie snacks and the introduction of finger foods, to make sure that nutritional needs are met. Residents are placed at risk of not receiving adequate nutrition, but lack of interventions when their weight decreases. Staff must make sure that food and fluid intake is accurately recorded, i.e. two spoonfuls (20mls) of soup taken. There has been improvement in assessments, care planning and recording of care, but this has been sporadic. Staff must make sure that the assessments are fully completed and include details of social history and interests. Care plans must be followed and give clear directions for care, for example night time routine. Daily records must accurately reflect the care given, for example whether a resident has had a bath or shower. This will make sure that residents’ needs are met. Further work needs to be done on death and dying and sexuality, to make sure that staff are comfortable with talking about these subjects with residents. It is important that residents’ wishes with regard to death and expressing sexuality are respected and carried out. Staff must also update information on residents to ensure that it is current. (see Health and Person Care section) Staff need to demonstrate an understanding of caring for persons with dementia and how their disease might present. This will avoid inappropriate comments being recorded. Religious needs of residents must be respected, and residents should not attend church services if they do not wish to or if their representatives state that the resident has no religion. Hazel Court Nursing Home DS0000019096.V300628.R01.S.doc Version 5.2 Page 7 Hazel Court must be a clean and pleasant place for residents to live in. The staff need to make sure that attention is paid to high dusting and elimination of odours to achieve this. 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. Hazel Court Nursing Home DS0000019096.V300628.R01.S.doc Version 5.2 Page 8 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.V300628.R01.S.doc Version 5.2 Page 9 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 and 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a site visit to this service. Residents received information prior to moving into the home. Assessments undertaken need to be completed fully to make sure that all needs are identified, in particular social issues. Residents are provided with a statement of terms and conditions, which gives information on what is included in the fee. EVIDENCE: All residents are admitted under a block contract with a Primary Care Trust, with copies of the contract kept by the home. One contract was noted to be signed and dated by the resident, but this must be achieved consistently. Two of the residents’ surveys indicated that they had received contracts; the other four had blank responses. Two residents indicated that they have received sufficient information about the service provided prior to moving into Hazel Court. Hazel Court Nursing Home DS0000019096.V300628.R01.S.doc Version 5.2 Page 10 Residents are assessed prior to and on admission. The single assessment process is done prior to admission involving the multi-disciplinary team with a copy available within the home. Staff need to make sure that that assessments of residents on admission to the home are fully completed, to make sure that all care needs are identified. Improvement needs to be made regarding social history and interests. One resident’s file included minimal detail on their background and the information should have been expanded to include details of birthdays and dates of marriage, as it was stated that the resident’s family were important to them. It was noted that the resident was married, but sexuality had been addressed as follows: ‘No accounts of [the resident] expressing sexuality.’ This gave no indication of staff understanding of what sexuality is and whether the resident and their spouse wished to have private time together to maintain their relationship. Preferred ways of addressing residents was noted to be included in the assessments. Specific likes and dislikes were not consistently recorded. Such as food and beverage preferences. There were details of specific aids residents required, such as dentures, glasses and hearing aids. Hazel Court Nursing Home DS0000019096.V300628.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a site visit to this service. Residents and their representatives are satisfied with the care given, however there is inconsistency in involving them in the care planning process. Each resident has a care plan and daily records are kept, the information must be improved to reflect identified care needs, interventions by other health professionals and staff, and what care has been given. Spiritual, relationship and issues relating to end of life care need to be addressed comprehensively, to evidence that residents are respected. The overall quality of medications is poor. Errors in administration and recording, and inadequate storage conditions were found that could put the health and welfare of residents at risk. EVIDENCE: Residents stated in their surveys that they thought their care needs were met. Relatives considered that staff understood individual needs and were satisfied with the support given. Comments from the relatives survey included: ‘Any concerns the staff have with [the resident] they always inform me.’ and ‘the staff are very sensitive and understanding to [the resident’s] disability. [The Hazel Court Nursing Home DS0000019096.V300628.R01.S.doc Version 5.2 Page 12 resident] is treated with respect in a friendly non-forceful way. Also their support for me has been (and continues) to be very helpful. Staff were able to speak with good knowledge about individual residents, but this is not reflected in the care documentation. Some care plans provide detailed information on how care needs are to be met. For example a night care plan had details of a resident’s preferred bed times and waking up times, with information on needs/habits before retiring to bed. However, another night care plan had the following information: ‘Taken to bed after supper, 6am-7am changed, 8:30am taken out of bed.’ the assessment of this particular resident was checked and information that had been gathered on sleeping was: ‘usually goes to bed late, but sometimes earlier than the usual times depending on whether [the resident] is tired or not.’ There was no indication of specific times; this information could have been obtained from the next of kin to inform the care planning process. It was noted that the resident’s representative had been involved in care planning. Risk assessments relating to moving and handling, skin integrity and nutrition were noted to be in care plans. Staff need to make sure that residents are not placed at risk of potential harm. Nutritional needs were not always recorded accurately and one resident required a specialist diet, but there was no record of any interventions, indicating that this need had or had not been met. One care plan examined had good details of catheter care. Daily records did not accurately detail care that had been given, entry such as ‘was washed, creamed and dressed’, [the resident] was changed dressed and put to the lounge’ and ‘Bag emptied made comfortable.’ This does not evidence that care has been given according to the care plans. There must be specific details on the care plans and the daily records, to make sure that residents received appropriate care and attention according to their assessed needs. Residents’ wishes on end of life care and death are not fully detailed within care plans. There is evidence that staff lack understanding of the bereavement process. One resident had recently suffered the death of their spouse and the daily records stated ‘[the resident] is still moaning about that’, which could indicate that even though the resident was in mourning, staff have not listened and allowed the resident to express their grief. It was also noted that care information had not been updated from when the resident attended the day centre, prior to moving into the home, as it was recorded in the section on sexuality that the resident had a good relationship with their spouse. On all the three plans examined religious preferences of residents were noted. Residents are enabled to attend religious services. One resident was recorded as attending religious services, even though it was stated that they had no Hazel Court Nursing Home DS0000019096.V300628.R01.S.doc Version 5.2 Page 13 religion. Staff must ensure that religious and spiritual beliefs of residents are respected. Pharmacy inspector’s report. All records relating to receipt, storage, administration and disposal of current medication were examined. Two staff members were interviewed. The current medication in stock was compared to the current records and medication not supplied in the monitored dosage system was counted and compared to the records. All medication was stored securely. The fridge temperature was recorded as being below the required temperature for over a month. This had not been detected so no action had been taken to rectify it. Only one item was stored in the fridge currently. Most medication is given from a monitored dosage container. Staff are able to check if medication has been given or not. When medication is not supplied in the Medication Dispensing System (MDS) there is a clear audit trail to check whether medication has been given correctly. One medication in stock did not match the medication on the administration record and the wrong medication had been recorded as being given for over a week. This had no direct impact on the resident, as the medications were similar. The correct medication was checked with the GP on the day of the visit and the record changed appropriately. From the records seen and the medication in stock one resident had not been given one of their medications for a month. This had not been picked up or reported. The correct medication was currently being given. Two residents had medication missing from the morning section of the monitored dosage system for the day of the visit but had not been signed as being given. The nurse initially said that the medication had not been given that morning but later admitted that the medication had been given but had not been recorded. The receipt of one resident’s medication had not been recorded accurately making it difficult to see if the correct medication had been given The reason for not giving medication to one resident had not been documented. All other records relating to receipt, administration and disposal of medication had been completed. The records showed any allergies and alterations to medication. The controlled drug cupboard does not comply with the Misuse of Drug (Safe custody) Regulations. This has no impact on the health or welfare of residents. Hazel Court Nursing Home DS0000019096.V300628.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a site visit to this service. Improvements have been made in provision of activities, but this requires more development to reflect residents’ choice. The home has open visiting arrangements and residents can entertain their family and friends in their own room, or use communal areas. Mealtimes are unhurried and staff are attentive to residents needs. However, there must be evidence of choice of beverage with meals and more emphasis on it being a social occasion. Staff need to develop skills to enable them to dealt more appropriately with persons who have dementia. EVIDENCE: Activities are planned each day for residents and there is a notice board in the main entrance which details the activities programme for the week. On the site visit it was noted that the activity was ‘What the Papers Say’, which was in progress in the lounge area. The activities co-ordinator was discussing current news with the residents. There was good interaction between the member of staff and the group of residents. The activities co-ordinator encouraged residents to read the newspaper themselves and talk about any articles that they found interesting. Hazel Court Nursing Home DS0000019096.V300628.R01.S.doc Version 5.2 Page 15 A comment from the staff surveys said that activities could be improved by outings to the seaside. Another suggestion was to have a social evening once a month. One relative stated in their survey that they thought activities were an area that could be improved. Relatives are able to maintain contact with their family and friends, as confirmed in a comment made by a relative in their survey: ‘Visiting is completely open. We are welcome at anytime.’ It was noted that one resident is enabled to go to the park with their spouse. Lunchtime was observed on the site visit. Residents were able to choose where they sat and were assisted to sit on dining chairs. Condiments were available and cloth napkins were in use. Plate guards and assisted cutlery was available if required. The meal served was hot, well presented and the portions were adequate. The smell of the food was appetising. Staff did not routinely check that the resident was satisfied with beverage offered; all residents were given orange cordial. Glasses were re-filled in a timely manner and the only issue was choice of drink. Staff interactions with residents at mealtimes require improvement comments such as ‘Why are you not eating’, ‘Eat up.’ and ‘ Do you want this’, does not show respect for the residents as people. One resident was picking up their cutlery and was told to ‘Put it down’. Staff need to show awareness of the residents mental condition and approach them in a sensitive manner. Residents were asked if they had finished their first course, but were not informed of what the pudding was, when it was served to them. It is not appropriate to state ‘Well done’ when a resident has finished their meal. Staff must make sure that residents’ choice of meals is reinforced when the meal is served and staff interactions respect the dignity of residents. Hazel Court Nursing Home DS0000019096.V300628.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a site visit to this service. The complaints procedure meets the minimum Standards and residents’ representatives are aware of how to make a complaint. There have been no referrals relating to Adult Protection, which is due to a lack of incidents. Staff have an understanding of when incidents should be reported. EVIDENCE: All relatives’ surveys indicated that they would know how to make a complaint. One comment from a relative was: ‘I would address my complaint (not expected) to the manager.’ Residents’ surveys, apart from one also knew how to make a complaint. The one resident who did not know how to complain, stated that they ‘didn’t know’. Staff must make sure that the resident or their representative is aware of how to make a complaint. Hazel Court has not received any complaints since the previous inspection and there have been no Protection of Vulnerable Adults investigations. CSCI has not received any concerns relating to Hazel Court since the previous inspection. Staff spoken with on the site visit indicated that that they have received training in protection of vulnerable adults, which included defining abuse. Hazel Court Nursing Home DS0000019096.V300628.R01.S.doc Version 5.2 Page 17 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 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a site visit to this service. Staff are attempting to make Hazel Court homely, but the décor is tired and old looking and there are unpleasant odours in one unit. EVIDENCE: Residents live in an environment, which the staff are trying to make more homely. The entrance to the home is welcoming and was noted to be clean and tidy. Repairs have been undertaken to the rail in the blue bathroom as required at the previous inspection. The was a smell of urine in the Green unit corridor, which was noted on the site visit. A relative commented on their survey that: ‘[the resident’s] room smelt of urine. The home must make sure that the environment is free from offensive odours and make sure that carpeting or flooring is cleaned or replaced as necessary. Attention needs to be paid to making sure that high dusting is done routinely to prevent the risk of infection. Hazel Court Nursing Home DS0000019096.V300628.R01.S.doc Version 5.2 Page 18 Residents are able to bring in personal items and care had been taken to make sure that photographs and ornaments were displayed attractively. Hazel Court Nursing Home DS0000019096.V300628.R01.S.doc Version 5.2 Page 19 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 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a site visit to this service. Staff are appropriately supervised and trained, however training needs to be put into practice consistently to make sure that residents have good care. EVIDENCE: Residents are supported by appropriate numbers of staff and there is a suitable skill mix. The staff member who greeted the inspector was aware of the need to have a name badge on and was wearing their badge. Staff said that they had received training in whistle blowing, dementia and bereavement and loss. It is important that this training is put into practice, to make sure that residents received appropriate care and are supported fully. There has been improvement to training records, which are now computerised. The administrator has organised a system whereby she is alerted when training is due for staff, and is able to book the required training. Evidence from previous inspections indicates that the recruitment procedure is followed and all necessary checks are carried out prior to an employee commencing. Hazel Court Nursing Home DS0000019096.V300628.R01.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a site visit to this service. Lack of a permanent manager has meant that the home has not been able to meet the Standards consistently. The staff team is strong and works in the best interests of the residents. EVIDENCE: The home has suffered through lack of a permanent manager for over a year. The staff team endeavour to provide the care the residents required. The inspector noted that the core staff team worked well together and has the best interests of the residents as the focus of their work. The CSCI has no concerns regarding the health and safety of residents, but a manager would enable the home to develop and meet all the standards effectively. Staff have worked hard to meet the majority of the requirements made at the previous inspection. Hazel Court Nursing Home DS0000019096.V300628.R01.S.doc Version 5.2 Page 21 Two staff members spoken with indicated that they supervised carers regularly and they themselves had received supervision from the area manager who is supporting the home, whilst a new manager is being recruited. The administrator confirmed that personal allowances are maintained by the home and there are records of transactions. Two relatives surveys indicated that they had Power of Attorney. Residents’ health and safety is protected through routine checks as detailed below. There has been significant improvement in the recording of hot water temperatures and fire drills since the previous inspection. Records showed that weekly fire alarm tests and testing of hot water temperatures had been achieved weekly and recorded. Emergency lighting is tested monthly and recorded. Fire exits are checked for obstruction and the records showed that monthly evacuations had taken place using a ‘parallel’ evacuation technique, with residents and staff. Regular resident/relatives meetings have not been commenced due to their being a lack of manager; this must be addressed once a manager has been appointed. Hazel Court Nursing Home DS0000019096.V300628.R01.S.doc Version 5.2 Page 22 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 3 2 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 2 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 3 X X 3 Hazel Court Nursing Home DS0000019096.V300628.R01.S.doc Version 5.2 Page 23 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 OP2 Regulation 12 (1) Requirement The registered person must ensure that residents or their representatives signed a copy of the terms and conditions. The registered person must ensure that assessments of residents are fully completed to make sure that care needs are identified. The registered person must ensure that care plans detail residents’ needs in full. (previous timescale of 21/04/06 not met) The registered person must ensure that daily records reflect the actual care given. The registered person must ensure that procedures are in place for staff if significant weight change is noted. (previous timescale of 21/04/06) The registered person must ensure that any errors in medication are detected and appropriate action taken. The registered person must ensure that staff complete all records accurately and changes DS0000019096.V300628.R01.S.doc Timescale for action 30/09/06 2. OP3 12 (1) 30/09/06 3. OP7 15 30/09/06 4. 5. OP7 OP8 17 (1) (a) & Sch 3 12 (1) 30/09/06 30/09/06 6. OP9 13 (2) 30/09/06 7. OP9 13 (2) 30/09/06 Hazel Court Nursing Home Version 5.2 Page 24 8. OP10 12 (4) (b) 9. OP11 12 (4) (a) 10. OP12 16 (2) (n) in medication are clearly recorded. The registered person must ensure that spiritual needs and relationship/sexuality needs are respected and maintained by the home. The registered person must ensure that end of life care and death and dying wishes are recorded and acted upon. The registered person must ensure that the activities programme is developed to reflect residents’ choice and include outings. The registered person must ensure that nutritional needs of persons with dementia are addressed in a variety of ways. The registered person must ensure that there is a choice of beverage at meal times. The registered person must ensure that staff are sensitive to residents mental health condition when serving meals. The registered person must ensure that the home is kept clean and free from offensive odours. The registered person must ensure that all training is put into practice. The registered person must ensure that staff received appropriate training of dementia. The registered person must ensure that a permanent manager is appointed at the home and registered with the CSCI. (previous timescale of 21/04/06 not met.) The registered person must ensure that regular residents and relatives meetings take place. DS0000019096.V300628.R01.S.doc 30/09/06 30/09/06 30/09/06 11. OP15 16 (2) (i) 30/09/06 12. 13. OP15 OP15 16 (2) (i) 12 (4) (a) 30/09/06 30/09/06 14. OP26 16 (2) (k) 30/09/06 15. 16. 17. OP30 OP30 OP31 12 (1) 18 (1) (c) 8 (1) a 30/09/06 30/09/06 30/09/06 18. OP33 12 (2) & 24 (1 & 3) 30/09/06 Hazel Court Nursing Home Version 5.2 Page 25 (previous timescale of 21/04/06 not met.) 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 Refer to Standard OP9 Good Practice Recommendations It is recommended that controlled drugs are stored in a cupboard that complies with the appropriate legislation. Hazel Court Nursing Home DS0000019096.V300628.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG 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. 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