Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 06/03/06 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 6th March 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.

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

The home provides a calm welcoming environment. Residents made positive comments regarding the food that they receive and about staff.

What has improved since the last inspection?

The employment of an activities worker should provide more structured activities for residents. An activities programme was displayed in the lounge. Resident`s wishes regarding terminal care and death were recorded in case files examined. These issues were requirements at the last inspection. The addition of a full time administrator has helped to improve records of residents finances and staff training.

What the care home could do better:

To ensure residents needs are met, care plans require updating. Procedures should be in place for staff to follow should residents weight indicate a significant change. Consistent records must be maintained of personal care tasks completed by staff. The published menu must reflect the meal served. The provision of `bibs` at meal times should be reviewed. The activities programme must reflect the activities provided to ensure residents have up to date information. The health and safety recording system must be reviewed. Fire procedures must be developed and displayed. A permanent manager must be appointed and registered with the CSCI to ensure consistency of care. Staff should wear their name badges to ensure that residents and visitors are aware of to whom they are speaking. The monthly visits by the registered person must be completed with a copy available at the home and a copy sent to the CSCI.

CARE HOMES FOR OLDER PEOPLE Hazel Court Nursing Home Haydon Way Wandsworth Off St Johns Hill London SW11 1YF Lead Inspector Emma Dove Unannounced Inspection 6th March 2006 10:30 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.V285844.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Hazel Court Nursing Home DS0000019096.V285844.R01.S.doc Version 5.1 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 24 Category(ies) of Dementia - over 65 years of age (24) registration, with number of places Hazel Court Nursing Home DS0000019096.V285844.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12/04/05 Brief Description of the Service: Hazel Court is a purpose built single storey care home. The home provides care for 24 persons who have dementia. Twenty-one people are currently residing at the home. Hazel Court is situated off St John’s Hill in Battersea. It is approximately twenty minutes walk from Clapham Junction Station and is accessible by bus. Accommodation is provided in single rooms, which 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 courtyard with seating for residents. Hazel Court Nursing Home DS0000019096.V285844.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over the course of four hours on the 6th March 2006 by two regulatory inspectors. The inspection consisted of examination of records, inspection of communal areas of the home and two residents bedrooms, talking with residents, the acting manager and staff. The inspectors had the opportunity to speak with seven residents and eight members of staff. What the service does well: What has improved since the last inspection? What they could do better: To ensure residents needs are met, care plans require updating. Procedures should be in place for staff to follow should residents weight indicate a significant change. Consistent records must be maintained of personal care tasks completed by staff. The published menu must reflect the meal served. The provision of ‘bibs’ at meal times should be reviewed. The activities programme must reflect the activities provided to ensure residents have up to date information. The health and safety recording system must be reviewed. Fire procedures must be developed and displayed. A permanent manager must be appointed and registered with the CSCI to ensure consistency of care. Staff should wear their name badges to ensure that residents and visitors are aware of to whom they are speaking. The monthly visits by the registered person must be completed with a copy available at the home and a copy sent to the CSCI. Hazel Court Nursing Home DS0000019096.V285844.R01.S.doc Version 5.1 Page 6 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.V285844.R01.S.doc Version 5.1 Page 7 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.V285844.R01.S.doc Version 5.1 Page 8 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 The Service Users Guide does not reflect the current regulatory authority. EVIDENCE: The Service Users Guide requires updating to include details of the CSCI to ensure that residents and their representatives have access to this information. Hazel Court Nursing Home DS0000019096.V285844.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 10 Residents needs are not fully met by care planning and recording systems in place. EVIDENCE: Three case files were examined which identified different standards of recording. One case file contained a detailed care plan which had been reviewed monthly; records of the individuals weight identified regular fluctuations with no record of actions taken; a pre admission assessment was in place; the Waterlow score had been added up incorrectly; a body map had been completed with no care plan in place or records indicating whether the sore had healed; monthly observations had been completed since August 2005 and details of GP visits and medical appointments were in place. One case file contained a photograph of the individual; brief background information; a brief assessment completed at the time of admission and daily records. A care plan had not been developed and information was not completed in full for this resident. This does not ensure staff have up to date information to meet the individuals needs. Hazel Court Nursing Home DS0000019096.V285844.R01.S.doc Version 5.1 Page 10 One case file contained detailed information regarding the individual’s needs and staff support required with a care plan, which had been reviewed. Recording regarding a health issue for the individual indicated that staff took appropriate actions and the resident received appropriate treatment. No issues or concerns were raised regarding resident’s privacy and dignity. Hazel Court Nursing Home DS0000019096.V285844.R01.S.doc Version 5.1 Page 11 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 Residents are encouraged to maintain social contacts. Activities do not always take place as planned. EVIDENCE: A member of staff has recently been employed at the home to provide activities. A list of activities was displayed in both lounges, however the activity scheduled on the day of inspection did not take place. Two residents were sitting at a table completing a jigsaw puzzle. Other residents were in the lounge where the television was on. One resident said ‘I enjoy watching television, although the screen is small’. The home’s Service User Guide makes clear that residents are encouraged to have visitors and in private if they wish. One resident confirmed that they can see visitors when they wanted to. A visitors book is maintained at the reception desk. The manager confirmed that residents are encouraged to make choices but that relatives are often relied upon to help make decisions on their behalf. Staff were observed to offer choices to residents which enables them to have some control in their daily life. Hazel Court Nursing Home DS0000019096.V285844.R01.S.doc Version 5.1 Page 12 The menu is displayed in the lounges, although the menu is in small print, which may be difficult for residents to see. The meal served at the time of inspection was not the published meal for the day. The cook reported that medical and religious diets are catered for and that staff complete menu request forms daily. Staff who spoke with inspectors were not clear that they completed menu request forms with residents. Residents comments regarding the food included ‘the food is good’, I have enough to eat’ and ‘the food is ok’. The inspectors observed ‘bibs’ in use for residents. This practice should be reviewed to ensure residents dignity is maintained. Hazel Court Nursing Home DS0000019096.V285844.R01.S.doc Version 5.1 Page 13 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): Standards 16 and 18 were assessed as met at the last inspection. EVIDENCE: Hazel Court Nursing Home DS0000019096.V285844.R01.S.doc Version 5.1 Page 14 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): 26 The home provides a clean environment for residents. EVIDENCE: A number of requirements were made at the last inspection in April 2005 and at an additional visits carried out in May and September 2005 relating to the environment. Carpeting in corridors have been replaced. Enforcement action has resulted in the reception area being more welcoming and homely. The areas of the home inspected were found to be clean and pleasant for residents. Hazel Court Nursing Home DS0000019096.V285844.R01.S.doc Version 5.1 Page 15 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): 28 Residents needs are met by a core group of permanent staff. Staff have access to appropriate training and development courses. EVIDENCE: The manager reported that the home is fully staffed. The published staffing rota identified two senior staff, five members of staff and the deputy manager on duty with the acting manager, domestic, catering and administrative staff also available. Staffing levels were observed to be appropriate to meet residents needs. Residents comments regarding staff included ‘he’s nice’ ‘staff are ok’ and ‘staff are helpful’. Staff made positive comments regarding working at the home, indicating that they had completed an induction of commencing employment and that they have opportunities to attend training courses. Name badges were not worn by all staff which does not help residents and relatives identify who they are speaking with. Hazel Court Nursing Home DS0000019096.V285844.R01.S.doc Version 5.1 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35 and 38 The health, safety and welfare of residents is compromised by poor recording systems. Resident finances are adequately protected. EVIDENCE: The home has had problems with vandalism and burglary during the past few months. The police have been involved and the manager said that they are considering installing CCTV. The home makes use of feedback forms which are given to residents and their relatives. Completed forms were seen although some of these were not dated. The deputy manager said that these would be discussed at relative meetings which should be held every 6 months. There was no evidence of when such a meeting was last held last year. It is not clear how unsatisfactory responses are dealt with. Hazel Court Nursing Home DS0000019096.V285844.R01.S.doc Version 5.1 Page 17 Resident finances are monitored by the administrator and the manager. The administrator had recently attended training on handling finances. The home holds cash at the home for some of the residents, which is held in a safe. The home holds larger sums of money for residents in a bank account. Satisfactory records are kept for individual residents monies. The home carries out regular audits for health and safety in the home. However it is not clear if any action results from the audit information. Water temperatures are checked on a monthly basis. In order to protect residents this must be done weekly. Records show that some temperatures were too low. There is no evidence of any action being taken to deal with this. The home has a fire manual which had a confusing system for recording drills and tests. The last fire drill was carried out on 6/2/06. There were no fire procedures in the manual and no procedures evident throughout the home or over fire points. Fire signs in the home were confusing. One sign pointed away from a fire exit. This presents a serious risk to residents, staff and visitors to the home. The handrail in the blue bathroom was loose and must be fixed. Hazel Court Nursing Home DS0000019096.V285844.R01.S.doc Version 5.1 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X X X X X 3 STAFFING Standard No Score 27 X 28 2 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 X X 1 Hazel Court Nursing Home DS0000019096.V285844.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 5 (1) Requirement The registered person must ensure that the Service Users Guide is reviewed and updated to include details of the CSCI. The registered person must ensure that care plans detail residents needs in full. The registered person must ensure that procedures are in place for staff if significant weight change is noted. The registered person must ensure that consistent records are maintained of personal care tasks. The registered person must ensure that the activities offered reflect the published programme. The registered person must ensure that the meals provided reflect the published menu. The registered person must ensure that a permanent manager is appointed at the home and registered with the CSCI. The registered person must ensure that regular residents and relatives meetings take place. DS0000019096.V285844.R01.S.doc Timescale for action 21/04/06 2 3 OP7 OP8 15 12 (1) 21/04/06 21/04/06 4 OP8 12 (1) 21/04/06 5 6 7 OP12 OP15 OP31 16 (2) n 16 (2) i 8 (1) a 07/04/06 07/04/06 21/04/06 8 OP33 12 (2) & 24 (1 & 3) 21/04/06 Hazel Court Nursing Home Version 5.1 Page 20 9 OP33 26 (2, 3, 4 & 5) 10 OP38 13 (4) 11 OP38 23 (4) 12 OP38 13 (4) c 13 OP38 23 (2) The registered person must ensure that a monthly visit is carried out with a report available at the home and a copy sent to the CSCI. The registered person must ensure that the health and safety monitoring and recording system are reviewed. The registered person must ensure that the fire procedure is displayed throughout the home and fire exits must be clearly identified. The registered person must ensure that hot water temperatures are tested weekly with records maintained and for clear guidance to be available should the temperature be too low. The registered person must ensure that the handrail in the blue bathroom is repaired. 21/04/06 21/04/06 07/04/06 07/04/06 07/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP15 OP15 OP28 Good Practice Recommendations The registered person should review the use of ‘bibs’ at mealtimes. The registered person should ensure that the menu is displayed appropriately in large print accessible to residents. The registered person should ensure that staff wear name badges. Hazel Court Nursing Home DS0000019096.V285844.R01.S.doc Version 5.1 Page 21 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. Extracts may not be used or reproduced without the express permission of CSCI Hazel Court Nursing Home DS0000019096.V285844.R01.S.doc Version 5.1 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!