Inspection on 19/09/05 for Hazelbrae

This inspection was carried out on 19th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Hazelbrae 19/09/07

Hazelbrae 31/10/06

Hazelbrae 21/04/05

Hazelbrae 28/09/04

Hazelbrae 14/04/04

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

CARE HOMES FOR OLDER PEOPLE Hazelbrae 76 St Saviours Road St Leonards Road East Sussex TN38 0AR Lead Inspector James Houston Announced 19 September 2005 10:00 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 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. Hazelbrae H59-H10 S21129 Hazelbrae V239092 190905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Hazelbrae Address 76 St Saviours Road St Leonards on Sea East Sussex TN38 0AR 01424 425080 01424 830686 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) Crowhurst Care Limited Mrs Susan Straughan Care Home 15 Category(ies) of Dementia (DE), 15 registration, with number of places Hazelbrae H59-H10 S21129 Hazelbrae V239092 190905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. That only service users with a dementia type illness may be admitted 2. The maximum number of service users to be accommodated will be fifteen (15) 3. The service users accommodated will be aged sixty-five (65) years of age or over on admission Date of last inspection 21 April 2005 Brief Description of the Service: Hazelbrae is a detached property situated in a residential area of St-Leonardson-Sea. Local shops are situated within walking distance. The town centre, shops and railway station are situated approximately one mile away. Residents private accomodation is situated on two floors. A stair lift is provided to assist access to the first floor. The home has a rear garden readily accessible to residents. Hazelbrae is registered to provide residential and social care to (15) older people who have a dementia type illness. The registered provider is Crowhurst Care Ltd. Mrs Susan Straughan is the registered manager. Hazelbrae H59-H10 S21129 Hazelbrae V239092 190905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over the morning and early afternoon of the nineteenth of September 2005. Before the inspection records held by the Commission for Social Care Inspection were read, as was pre-inspection material completed by the home. Standards to be inspected were prepared. The inspection itself lasted five hours. The home’s owners, the manager, six staff, six residents and three relatives were spoken to during the inspection. Written comments from or on behalf of seven residents, and from twelve relatives or visitors, and two visiting professionals were received and the results included in the information informing the inspection. A tour of the whole premises was made, and files, records and policies were read. Fifteen residents were living in the home on the day of the inspection. 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. Hazelbrae H59-H10 S21129 Hazelbrae V239092 190905 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Hazelbrae H59-H10 S21129 Hazelbrae V239092 190905 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2,4 and 6. Clear written agreements about residence are in place. The home meets the needs of the current resident group. EVIDENCE: The home has a suitable contract with residents. It contains the details set out in this standard. Records inspected showed that a copy is retained on the files of residents. The home was able to demonstrate that it can meet the needs of residents. Interaction observed between staff and residents showed respect and encouragement. The home does not at present offer intermediate care, nor is it their intention to do so. Hazelbrae H59-H10 S21129 Hazelbrae V239092 190905 Stage 4.doc Version 1.40 Page 8 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 standard(s) 7,9 and 10. The home has comprehensive care plans. The medication systems are suitably maintained. Residents’ privacy and dignity are respected. EVIDENCE: Five care plans were inspected at random. They contain thorough care planning documentation and needs assessments that are completed, and reviewed on a regular basis. Risk assessments are recorded and updated. Staff said that they have access to care plans and write in records about care given. Records inspected were up to date and well written. Staff said that they had had training in writing in records. Relatives confirmed that they and the resident had been involved in the drawing up of the care plan and that they had signed a copy of their relative’s care plan. The home operates a key worker system. Medicines are securely stored. No residents currently self-medicate. The record of drugs administered was inspected and found to be fully recorded. Relatives said that the home dealt with the medication of their relative appropriately. No controlled drugs are held at present, but the facility to do so exists. Records inspected showed that staff who administer drugs have had training from a pharmacist. Records showed that a pharmacist visits regularly to inspect the home’s systems. Hazelbrae H59-H10 S21129 Hazelbrae V239092 190905 Stage 4.doc Version 1.40 Page 9 The manager confirmed that staff are taken through the crucial importance of treating residents with dignity as part of their induction training. Relatives confirmed that they consider that residents are treated with respect. The home, which is fully occupied, has two shared rooms and the manager and staff considered that the physical configuration of these rooms and the needs of the particular residents mean that the use of screens is not indicated at present. The manager will review this over time. Hazelbrae H59-H10 S21129 Hazelbrae V239092 190905 Stage 4.doc Version 1.40 Page 10 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 standard(s) 12,14 and 15. Social activities and food served are well managed and provide daily variation and interest for people living in the home. The home’s ethos is to maximise choice for residents. EVIDENCE: Staff provide activities for residents who want to join in. The activities for the day are listed on a board in the lounge. A resident said that they enjoy them. An outside body visits monthly to provide other activities. Staff said that musical activities are particularly enjoyed. Volunteers take out one resident to a local church. Residents do not go out on their own but several are taken out by family and friends. The manager takes residents out regularly, either on her own or with a staff member. The manager said that residents are encouraged, as far as is possible to make decisions, for example whether to attend activities or not. Staff were seen to take time to consider with residents possible courses of action. Residents and relatives said that the food served in the home is good. The meal served during the inspection appeared appetising and in ample portions. The home keeps careful records of food served and alternatives given. Special diets are catered for, and staff said that they have the time to give discreet assistance to residents who need it. Residents can choose to eat in the lounge or in the dining room. Hazelbrae H59-H10 S21129 Hazelbrae V239092 190905 Stage 4.doc Version 1.40 Page 11 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 standard(s) 16 and 18. The home deals satisfactorily with complaints made to it. The home’s systems are designed to deal with any abuse or allegations of abuse. EVIDENCE: The home has a complaints policy that explains clearly to residents and their families how complaints can be made and includes reference to the Commission for Social Care Inspection. The home has received three complaints or expressions of concern over the past year, and examination of records kept shows that these have been dealt with appropriately. The Commission of Social Care Inspection has received no complaints regarding the conduct of the home. The home has a suitable adult protection policy. The whistle-blowing policy needed a minor amendment, which was made during the inspection. Staff said that they have received suitable training on adult protection and dealing with challenging behaviour and records inspected confirmed this. The procedures have not had to be invoked in respect of any adult in the home. The home has a policy in respect of any gifts received from residents, and staff confirmed that they are aware of it. Hazelbrae H59-H10 S21129 Hazelbrae V239092 190905 Stage 4.doc Version 1.40 Page 12 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 standard(s) 19,20,24 and 26. The home is maintained to a good standard, and the communal rooms and bedrooms are well presented. The laundry facilities are suitable. EVIDENCE: The home is a large detached building on two floors. A programme of renewal and redecoration is in place. The dining room has been redecorated since the last inspection. Some minor items, such as small areas of exterior paintwork at the front, and two washbasin lights need attention. The home meets the standards of the local fire officer and environmental health officer. The home has a large, safe and tidy garden, that is accessible to residents, and residents and visitors were sitting out in it during the inspection. Residents said how much they enjoyed this facility. A large extension to the home giving a new lounge and kitchen, a shaft lift and manager’s office and new bedrooms is planned. The home has a dining room and a lounge area with a small adjoining conservatory. These rooms are well decorated and comfortably furnished. Lighting is domestic in nature. Hazelbrae H59-H10 S21129 Hazelbrae V239092 190905 Stage 4.doc Version 1.40 Page 13 Residents’ rooms are well decorated and furnished. Residents said that they like their rooms. Inspection showed that they have been personalised. An inventory of each resident’s furniture and possessions is held on file, and was available for inspection. The home’s laundry is sited away from food preparation areas, and is suitably equipped. Relatives said that the home’s laundry service works satisfactorily. The home was clean and tidy throughout and there were no odours. Hazelbrae H59-H10 S21129 Hazelbrae V239092 190905 Stage 4.doc Version 1.40 Page 14 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29 and 30. The needs of residents are met by a competent staff group. Considerable attention is given to the training of staff. Recruitment processes are robust. EVIDENCE: Observation of staff working with residents showed that they are aware of residents’ needs and able to meet them. Residents and relatives said that staff are helpful. A relative said that they had observed that staff respond quickly to calls for assistance from residents. A rota was available for inspection and it showed that sufficient staff, including ancillary staff, are on duty in the home to meet the needs of residents. The manager said that staff left in charge are always aged at least twenty one. The rota shows an on-call system, and staff confirmed that when they have needed to avail themselves of this, the response has been helpful. Staff and relatives said that staff turnover is low. Agency staff are not used. The home has 12 care staff, of whom six hold NVQ in care, four at level 3 and two at level 2. This meets the recommended level of qualification. The manager said that three other staff are commencing NVQ level 2 in care shortly. The home’s staff recruitment records for newly appointed staff were inspected, and were found to contain the required information. Staff confirmed that they receive job descriptions, contracts, and a copy of the General Social Care Council Code of Conduct. Hazelbrae H59-H10 S21129 Hazelbrae V239092 190905 Stage 4.doc Version 1.40 Page 15 Records inspected showed that staff receive induction training and that a range of other training is provided. An individual portfolio on each staff member is held and these were available for inspection. A staff member said that they get training on “everything going”. Hazelbrae H59-H10 S21129 Hazelbrae V239092 190905 Stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,35,36 and 38. The manager is able to discharge her responsibilities. The home is running well and the atmosphere is good. Handling of residents’ monies is satisfactory. Staff receive regular supervision. The health and safety of residents and staff is protected. EVIDENCE: The manager has extensive relevant experience. She is familiar with the diseases and conditions associated with old age, and records inspected showed that she undertakes regular training to update her knowledge and skills. She is completing her NVQ level 4 in care and plans to complete her Registered Managers Award early in 2006. Staff said that they feel able to put forward ideas as to how the home should be run. There are regular minuted staff meetings, the notes of which were available for inspection, and staff said that these are made available to them. Hazelbrae H59-H10 S21129 Hazelbrae V239092 190905 Stage 4.doc Version 1.40 Page 17 Relatives said that the manager is very helpful. The home does not at present hold valuables for residents but the facility to do so exists should the need arise. The manager holds monies for eight residents, and for two records chosen at random the balance recorded in the book tallied with monies held. Staff said that they receive regular supervision and records inspected confirmed that staff receive formal recorded supervision at least six times a year. The home has carried out fire risk assessments and environment risk assessments recently. The record of incidents was inspected and was fully kept. Hot water temperatures and water tank temperatures are checked regularly and results recorded. Windows opening widths were seen to be restricted, and windows are regularly checked. The home’s gas and electricity systems are regularly checked and portable appliances tested periodically. Staff said that they had had training in moving and handling, fire safety, first aid, food hygiene and infection control, and records inspected confirmed this. Hazelbrae H59-H10 S21129 Hazelbrae V239092 190905 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 x 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 3 COMPLAINTS AND PROTECTION 2 3 x x x 3 x 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 Standard No 16 17 18 Score 3 x 3 3 3 x x 3 3 x 3 Hazelbrae H59-H10 S21129 Hazelbrae V239092 190905 Stage 4.doc Version 1.40 Page 19 No 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. Standard Regulation Requirement Timescale for action 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. Refer to Standard 10 19 Good Practice Recommendations Review provision of screens in shared rooms. Review minor physical items as identified at inspection. Hazelbrae H59-H10 S21129 Hazelbrae V239092 190905 Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection Ivy House 3 Ivy Terrace Eastbourne East Susssex BN21 4QT 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 Hazelbrae H59-H10 S21129 Hazelbrae V239092 190905 Stage 4.doc Version 1.40 Page 21 - 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. 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