Inspection on 28/04/05 for Hazel Mead

This inspection was carried out on 28th April 2005.

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 Mead 27/06/07

Hazel Mead 02/11/06

Hazel Mead 09/05/06

Hazel Mead 06/09/05

Hazel Mead 15/12/04

Hazel Mead 18/06/04

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Prince Bishop Court

Park View (15)

Craigmore House

1 Lanark Close

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

CARE HOME ADULTS 18-65 Hazel Mead 3 Elpha Court South Broomhill Morpeth, Northumberland NE65 9RR Lead Inspector Elaine Wright Unannounced 28 April 2005 09:30 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 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 Mead B53-B03 S40943 Hazel Mead V220967 280405 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Hazel Mead Address 3 Elpha Court South Broomhill Morpeth Northumberland NE65 9RR 01670 761741 01670 761351 elsie@elpha.totalserve.co.uk Mrs Elsie Hazel Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Elsie Hazel CRH 5 Category(ies) of LD Learning disabilitiy (5) registration, with number of places Hazel Mead B53-B03 S40943 Hazel Mead V220967 280405 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: There were no conditions applying at the time of this inspection. Date of last inspection 15 December 2004 Brief Description of the Service: Hazel Mead is a purpose-built bungalow providing ensuite accommodation for 5 younger adults with a learning disability. Hazel Mead shares the grounds with Elpha Lodge, a care home for younger adults with physical disabilities. The bungalow has level access to all accommodation both internally and externally and is decorated and furnished to a good standard. The home is close to local facilities and transport networks and service users also have access to transport shared with Elpha Lodge. Nursing care is not provided. Hazel Mead B53-B03 S40943 Hazel Mead V220967 280405 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection by Elaine Wright and Fiona Millns took place on the 28 April 2005, at 11:00 am and lasted until 2:30 pm. The focus of the inspection was to follow up on progress being made following the issuing of Enforcement Notices in January 2005, and requirements made at the previous inspection carried out on the 15 December 2004. Service user records were examined together with the fire log, accident books, communication books, supervision and training records. The Inspectors spoke to 3 service users, the manager and two members of staff. What the service does well: What has improved since the last inspection? Improvements in the care planning process identified under the specific standards in this report showed that service users had developed and maintained skills and that ‘behaviours’ have improved. Staff have already received training in record-keeping and in the Protection of Vulnerable Adults (POVA) and, together with the service users, had attended an Awareness Day on Person Centred Planning (PCP). Further staff training in Hazel Mead B53-B03 S40943 Hazel Mead V220967 280405 Stage 4.doc Version 1.20 Page 6 areas identified at the previous inspection is planned over the forthcoming months. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Hazel Mead B53-B03 S40943 Hazel Mead V220967 280405 Stage 4.doc Version 1.20 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Hazel Mead B53-B03 S40943 Hazel Mead V220967 280405 Stage 4.doc Version 1.20 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 and 3. The manager and staff have shown a commitment to improving their skills through training, which will increase the involvement of service users in care planning, and updating risk assessments and care plans. Stronger links have also been established with Social Services personnel to review care plans and risk assessements with a view to ensuring the home can meet the needs of service users. EVIDENCE: The service users who live in Hazel Mead at the present time all moved in in March 2002. Documentation to enable assessments for prospective new service users is in place and the manager is aware of the need to obtain a full professional assessment prior to any new admissions. The quality of the admission process and opportunities given to prospective new service users will be assessed when a vacancy arises. Work has been carried out, in consultation with Care Managers, to improve the quality of risk assessments in the home and the staff are to attend risk assessment training in May 2005. There are limited educational, employment, and social opportunities for service users. It was evident that commitment had been made to improving the quality of records. Monthly evaluations are not outcome based and do not indicate what Hazel Mead B53-B03 S40943 Hazel Mead V220967 280405 Stage 4.doc Version 1.20 Page 9 involvement the service user has had or what had actually occurred. Additionally, it was noted that a recent incident in a day-care setting had not been recorded in the communication record. Staff and service users had had the opportunity to attend an Awareness Day to facilitate the introduction of Person Centred Planning (PCP). Hazel Mead B53-B03 S40943 Hazel Mead V220967 280405 Stage 4.doc Version 1.20 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) And and 6, 7, 8 and 9. Service users are consulted about the running of the home and are being encouraged, through the process of PCP, to make life plans. Risk-taking is part of the promotion of independence in the home. EVIDENCE: Improved links with Social Services staff have been established and the needs of all service users have been jointly reviewed. It was evident from records examined that a lot of work had been done to organise service users plans with a view to the introduction or of PCP. Both staff and service users had attended an Awareness Day on PCP and the manager advised the Inspectors that one service user was due to meet their facilitator in early May. A range of care plans were in place for each service user however there were still some basic care plans for example, on showering, missing. An examination it was found that the monthly evaluations of care plans were out come based only on a few occasions. Service users are not always involved in reviewing and evaluating plans. Monthly evaluations do not include evidence that outcomes are being met. Hazel Mead B53-B03 S40943 Hazel Mead V220967 280405 Stage 4.doc Version 1.20 Page 11 The record of evaluations for one service user showed that more confidence had been gained when travelling on a bus, and another evaluation evidenced improvements in mental health. It was not possible to evidence from service user records that they were aware of and had access to an advocate. The ability of service users and the roles they played in the management of their finances could not be evidence from care plans. This area of care was not thoroughly examined at this inspection but will be reviewed again at the next inspection. The records of house meetings showed that residents are consulted about staff and about household activities. It was also evident from staff supervision records that issues raised by service users had been addressed by the manager. Throughout the course of the inspection service users took the opportunity to visit the inspectors who were working in the office, to chat Inspectors and showed them around the home. Hazel Mead B53-B03 S40943 Hazel Mead V220967 280405 Stage 4.doc Version 1.20 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 15 and 16. Access to educational opportunities employment and activities are available but limited. Service users are involved with activities in the local community and also enjoy the opportunity to eat out, attend shows and local clubs. EVIDENCE: Service users care records show plans for activities and leisure interests. They also indicated that the personal needs of some service users limit their ability to join in some activities. The activities recorded were repetitive and there was no evidence to show that new and different activities or social opportunities were being explored. Group activities/social outings take place on a regular basis but again these are of a repetitive nature. Evidence in staff records indicated that staff themselves considered that more individual activities would be better for the service users. Two service users regularly visit the local pub independently and/or supported by staff. Additionally, one service user goes out to work on at least two days per week. Hazel Mead B53-B03 S40943 Hazel Mead V220967 280405 Stage 4.doc Version 1.20 Page 13 Adult Training Centre (ATC) and college courses in computers, cookery, food hygiene, media, and a garden project are being attended by service users. In house activities include board games, beauty therapy and music. Two service users also enjoy swimming and attending Shadowdance. It was noted that some recordings in connection with service users leisure opportunities included daily living tasks. Visitors are always made welcome to the home and service users take the opportunity, when they choose, to visit their friends in Elpha Lodge. Included in the service users pen pictures were notes on contact with family, and regular visits home. Arrangements had been made for the service users to have the opportunity of a postal vote in the forthcoming election. Two service users took the opportunity to discuss with the Inspectors the forthcoming holiday to Primrose Valley where they had also enjoyed a holiday last year. Each service user has access to a range of equipment within their own bedroom on which they can play music, watch television, and use computers. Household music and television equipment is located in the lounge and dining room. During the inspection service users were observed clearly making choices about what activities they were taking part in and what music was being played. Service users do undertake some light household tasks but this is very much a personal choice. Several service users enjoy helping with meal preparation and cooking. One service user brought the local newspaper to show the Inspectors - he had his photograph in the paper when he received a sports award at a recent Presentation Evening. He was very proud of his achievements. Hazel Mead B53-B03 S40943 Hazel Mead V220967 280405 Stage 4.doc Version 1.20 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 20, and 21. The management of medication within this home is of a good standard and records are well maintained. Service users are able to self medicate if they wish. Access to medical care is promoted by staff. EVIDENCE: One service users records indicated that personal hygiene could be an issue however there was no care plan in place in support of this. Records detailing when support had been given with personal care were kept in two places, this resulted in incomplete records being included in the service users plan. Records were found to be up-to-date for a service user who is required to attend a Newcastle hospital on a regular basis. The records also indicated that doctors were pleased with the service users progress. The medication and associated Medication Administration Records (MAR) were examined for each service user. All were found to be up-to-date and fully complete. Medication is stored securely within the home. Service users who wish are able to self administer medications. The records clearly indicated where one service user regularly changed their mind about where creams were stored ie., in their bedroom or the medication store. A staff signature and initial list was in place and fully complete. Hazel Mead B53-B03 S40943 Hazel Mead V220967 280405 Stage 4.doc Version 1.20 Page 15 Staff have not received training in the process of ageing, dying and death. Hazel Mead B53-B03 S40943 Hazel Mead V220967 280405 Stage 4.doc Version 1.20 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23. Staff are now trained in POVA procedures and report issues, via Regulation 37 notifications, appropriately to CSCI. EVIDENCE: A recent “incident” had not been recorded in the communications book or as a complaint. Full details had however been forwarded to CSCI. There is not always consistency when recording such matters. The manager and staff had all attended POVA training and a new file containing up to date guidance and copies of CSCI Regulation 37 reporting forms was found to be in place. All staff had signed to say they had read the guidance and attended a half day, in-house, training session. Team meeting notes recorded a whistle blowing incident and identified a member of staff contrary to whistle blowing procedrues. Hazel Mead B53-B03 S40943 Hazel Mead V220967 280405 Stage 4.doc Version 1.20 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) None of the environmental standards were assessed at this inspection. EVIDENCE: Hazel Mead B53-B03 S40943 Hazel Mead V220967 280405 Stage 4.doc Version 1.20 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 35 and 36. Staff are clear about their roles and responsibilities. Further training is required to develop the competencies of staff. EVIDENCE: Staff meeting records identified that individual roles and responsibilities had been discussed and notes were readily available on the role of the key worker. Staff supervision records were more detailed and identified that issues relating to staff capability and/or training needs had been identified and addressed. Copies of the General Social Care Council (GSSC) code of conduct have been issued to all staff. All staff are trained to a minimum of NVQ level 2 although further training input relating to caring for adults with a learning disability has previously been identified and is presently being discussed with training providers. Training in record keeping, recording with care, first aid, food hygiene and risk assessment has been provided and certificates of attendance were seen. Hazel Mead B53-B03 S40943 Hazel Mead V220967 280405 Stage 4.doc Version 1.20 Page 19 Supervision records for three staff members were reviewed together with annual appraisal documentation. The appraisal system in place at Hazel Mead includes the identification of training needs, strengths, weaknesses and the outcome agreed by both the appraisor and appraisee. Hazel Mead B53-B03 S40943 Hazel Mead V220967 280405 Stage 4.doc Version 1.20 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 41 and 42. Systems are in place and training and health and safety checks are undertaken/recorded to protect and promote the safety of service users living in the home. EVIDENCE: Considerable work has been undertaken since the last inspection to update service users individual records and streamline staff access to policies, procedures and guidance. The fire log book and accident recording records were examined. All were found to be up to date, well recorded and fire records included details of drills undertaken by staff and service users together with signatures of attendance. Safe storage arrangements are in place for Control of Substances Hazardous to Health (COSHH) products and guidance on their use is readily available. The Inspector was able to see up to date maintenance and servicing agreements which included checks for legionella and the safety of equipment. Fire and the Hazel Mead B53-B03 S40943 Hazel Mead V220967 280405 Stage 4.doc Version 1.20 Page 21 use of oxygen risk assessments are in place and signed by staff. A pictorial fire safety notice is also displayed within the home to simplify arrangements for service users. SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 2 2 x x Standard No 22 23 ENVIRONMENT Score 2 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 2 2 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x x Standard No Hazel Mead Standard No 31 32 Score 3 2 Version 1.20 Page 22 B53-B03 S40943 Hazel Mead V220967 280405 Stage 4.doc 11 12 13 14 15 16 17 x 2 2 2 2 2 x 33 34 35 36 x x 2 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 x 3 1 Standard No 37 38 39 40 41 42 43 Score x x x x 3 3 x Hazel Mead B53-B03 S40943 Hazel Mead V220967 280405 Stage 4.doc Version 1.20 Page 23 YES Are there any outstanding requirements from the last inspection? 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. 2. Standard Regulation Requirement Staff must receive the planned training in risk assessment. Monthly evaluations must be outcome based and include service users involvement and evidence of achievement. Communication records must be kept up to date. Service users choices/wishes and opportunities must be expanded and clearly identified in the service users plan. (Previous timescale of 28 April 2005, partially met.) The introduction of PCP must be continued. (Previous timescale of 28 April 2005, partially met.) Care plans must be established to support activities of daily living ie., bathing. Service users access to advocates must be promoted. Staff must receive training in the process of ageing, dying and death. Staff must receive additional training in conditions and behaviours associated with a learning disability. (Previous timescale of 28 April 2005, partially met.) Timescale for action 31 May 2005 30 July 2005 30 June 2005 30 August 2005 2, 6, 7, and 18(1) 9 3, 9, 22 15 and 41 3 and 41 6, 12, 13, 14, 15 and 16 17 15 3. 4. 5. 6. 7. 8. 9. 6 and 7 6, 7, 8, 18 and 41 7 21 32 and 35 15 15 14(1) 18(1) 18(1) 30 August 2005 30 June 2005 30 June 2005 18 July 2005 30 August 2005 Hazel Mead B53-B03 S40943 Hazel Mead V220967 280405 Stage 4.doc Version 1.20 Page 24 10. 39 24 The quality assurance system must be reviewed to ensure that it meets the requirements of Regulation 24. (Previous timescale of 18 July 2005, not yet expired.) 18 July 2005 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 7 18 22 Good Practice Recommendations Contingency plans should be established for service users attending day care. Only one set of personal care recordings should be maintained. Staff should be reminded of their responsibilities associated with the disclosure of poor practice and whistle blowing. Hazel Mead B53-B03 S40943 Hazel Mead V220967 280405 Stage 4.doc Version 1.20 Page 25 Commission for Social Care Inspection Northumbria House Manor Walks, Cramlington Northumberland NE23 6UR 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 Mead B53-B03 S40943 Hazel Mead V220967 280405 Stage 4.doc Version 1.20 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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