Inspection on 19/09/07 for Hazelbrae

This inspection was carried out on 19th September 2007.

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

Other inspections for this house

Hazelbrae 31/10/06

Hazelbrae 19/09/05

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-on-sea East Sussex TN38 0AR Lead Inspector Melanie Freeman Unannounced Inspection 19th September 2007 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 Hazelbrae DS0000021129.V346337.R03.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. Hazelbrae DS0000021129.V346337.R03.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hazelbrae Address 76 St Saviours Road St Leonards-on-sea East Sussex TN38 0AR 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) 01424 425080 01424 830686 Crowhurst Care Limited Mrs Susan Straughan Care Home 15 Category(ies) of Dementia (15) registration, with number of places Hazelbrae DS0000021129.V346337.R03.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. That only service users with a dementia type illness may be admitted. The maximum number of service users to be accommodated will be fifteen (15). The service users accommodated will be aged sixty-five (65) years of age or over on admission. 31st October 2006 Date of last inspection Brief Description of the Service: Hazelbrae is a detached property situated in a residential area of St-Leonard’son-Sea. Local shops are situated within walking distance. The town centre, shops and railway station are situated approximately one mile away. Residents private accommodation 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. The home provides care and support to residents who are both privately funded and those who are funded by Social Services. The home’s fees as from 01 April 2007 range from a basic fee of £410.02 per person per week depending on the room to be occupied and the care needs of the individual. Additional costs are charged for chiropody, hairdressing, newspapers toiletries and a charge of £6 is made for physical motivation an activity available in the home. Hazelbrae DS0000021129.V346337.R03.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001 often use the term ‘service user’ to describe those living in care home settings. For the purpose of this report those living at Hazelbrae care home will be referred to as ‘residents’. This was a key inspection that included an unannounced visit to the home and follow up contact with resident’s representatives and visiting social/health care professionals. The unannounced assessment visit was facilitated by the senior carer on duty who received the direct feedback from the inspector. Mr and Mrs Detheridge the registered homeowners also arrived at midday, Mr Detheridge continued with the homes redecoration and Mrs Detheridge helped with the inspection process. On the day of the home visit the inspector spent most of her time observing practice in the home talking to the staff and spending time with the residents. The inspector was able to eat a midday meal with the residents in the communal dining room and review the arrangements for providing suitable diets. During the inspection visit four staff members were interviewed in private along with one visitor. Following the visit two residents relatives and three visiting health/social care professionals were contacted by telephone. In addition six surveys were sent to the Commission for Social Care Inspection, which contained the views of residents, their representatives and a visiting health care professional. Information provided by the home within the Annual Quality Assurance Assessment (AQAA) has also been included in this report. What the service does well: The home provides prospective residents and their families, with a good level of information about what services are provided at the home. The admission procedure allows for a comprehensive assessment process of any prospective resident. The staff and management of the home are welcoming to all visitors and visiting is unrestricted. Feedback from all sources was complimentary about the staff working in the home and comments again said that ‘nothing is too much trouble for the staff’. The home manager has an approachable manner and both staff and relatives said she was a good support. The home continues to give good care in a homely and friendly atmosphere. Hazelbrae DS0000021129.V346337.R03.S.doc Version 5.2 Page 6 The quality and standard of the food in the home is good and residents complimented the food. Staff recruitment was found to be robust and thorough and staff training is well promoted and documented. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Hazelbrae DS0000021129.V346337.R03.S.doc Version 5.2 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 Hazelbrae DS0000021129.V346337.R03.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides prospective residents and relatives, with a good level of information about the home, its facilities, services and the costs involved. The admission procedures ensures prospective residents are suitably assessed prior to their admission by a competent person, who ensures that the home admits only those residents who’s needs can be met by the home. Intermediate care is not provided at Hazelbrae. EVIDENCE: Hazelbrae DS0000021129.V346337.R03.S.doc Version 5.2 Page 9 There is a copy of the homes statement of purpose and service users guide displayed in the front entrance along with the homes registration certificate. This was informative and included a copy of the last inspection report. There was evidence that assessments are completed before admission and that this is used with information provided from social services to ensure a full assessment process is followed. In addition the assessment document used by the home has an area for the prospective resident or they’re relative to provide more individual information. This promotes a person centred approach. A relative spoken said that Hazelbrae had been recommended to her family and the admission was well managed. All pre-admission assessment are completed by the registered manager and the documentation completed is incorporated into the homes care documentation for each resident. Although Mrs Detheridge advised that all prospective residents or their representatives are advised verbally that following the assessment the home is able to meet their needs she was not able to confirm that this was also confirmed in writing in accordance with the required documentation. Intermediate or rehabilitative care is not provided at Hazelbrae Care Home. Hazelbrae DS0000021129.V346337.R03.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Resident’s health and care needs are set out in an individual plan of care. Resident’s care needs are met taking into account resident’s dignity with evidence of regular input from health care professionals as necessary. The arrangements for medicine administration in the home were found to be safe. EVIDENCE: The care documentation pertaining to three residents was reviewed as part of the inspection process and each of these residents were met with during the inspection visit to the home. . It was pleasing to note that the care Hazelbrae DS0000021129.V346337.R03.S.doc Version 5.2 Page 11 documentation recorded residents preferred term of address and that staff used this. The plans of care were found to be clear and to cover the health care needs of each resident and to provide detail on what each resident is able to do for himself or herself. The records indicated that the care plans are reviewed regularly and that residents or their representatives are involved and consulted with as part of the planning care process. Each resident has a recent photograph held within his or her individual records. Daily records are maintained and these are held within the care documentation and are completed by the care staff. The home operates a key worker system where by an identified carer takes a specific interest in a small group of residents, they also take responsibility for maintaining the care documentation and providing up to date information for the regular review of the care provided. Risk assessments are used to inform the care and included the risk of falls, moving and handling, continence and pressure area assessments. A nutritional screening/assessment is not routinely recorded and this was discussed with the senior carer. It was also noted that the social and psychological needs of residents are not fully explored within the care documentation and individual specific care preferences for example around what time resident like to get up in the morning need to be recorded. Observations confirmed that residents were clean and well looked after and staff responded to them in a patient and sympathetic way. Many of the residents were feeling unwell with the effects of a cold and staff had responded to this with referring health issues to the local doctors. Residents and relatives spoken to were positive with regard to the care provided in the home and comments included ‘I am very happy here’ ‘the home is lovely I am perfectly happy with the care and I feel the home does a superb job’ ‘I am happy with the care and my mother says that she is happy here too’. The medicine records examined were found to be full and accurate and practice observed was seen to be safe. The storage arrangements have been improved since the last inspection with the medicines being moved to a more suitable area in the home. The medicines are now held in a secure metal cupboard in the dining room. The home however still does not have suitable storage arrangements for controlled drugs and Mrs Dethridge assured that this would be provided if needed. Some residents are on medicines on an ‘as required’ basis and the need to provide individual guidance to staff on when to give this medication was discussed with the senior carer and Mr Detheridge along with the need to have a record of each staff members signature who administers medicines for auditing purposes. Hazelbrae DS0000021129.V346337.R03.S.doc Version 5.2 Page 12 During the inspection staff were seen to speak and treat residents with respect and appeared very kind and friendly. Resident’s individual rooms were personalised with many of them having their own possessions around them. Hazelbrae DS0000021129.V346337.R03.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Links with friends and relatives are encouraged and choices made are respected. The provision of meals ensures residents have a choice and variety in their diet and the arrangements for activities provide an interaction and some group entertainment. EVIDENCE: During the unannounced visit to the home staff were found to be interacting with residents in a positive manner. The home has an allocated staff member that works in the home four afternoons a week providing approximately one hour for activities. On the day of this visit she was doing some ball games with residents with other care staff. Hazelbrae DS0000021129.V346337.R03.S.doc Version 5.2 Page 14 Music is also played in the home and this is greatly enjoyed by some of the residents. Staff were able to describe what residents liked to do with their time and this included being involved in some domestic activities around the home. These individual preferences and how this can be accommodated was not recorded in the care documentation. Discussion took place with the senior carer around the need to expand on the social and psychological needs of residents that should be assessed and developed with the plan of care. The staff employed for the promotion of activities has not been trained in this important area and needs to be suitably trained and supported in order to promote meaningful individual activity and entertainment for residents. Some external entertainment is provided and includes a motivational therapist who promotes physical and mental stimulation and visits the home on a monthly basis. Visiting is well promoted and encouraged with no restrictions, the visitor spoken to said that she was always welcomed when she arrived and offered a beverage. Staff were also mindful of providing privacy and space for this visitor to speak to her mother in comfortable surroundings. The local vicar visits the home once a fortnight none of the residents attend the church. The meal eaten with residents was attractive and well enjoyed by residents who were assisted by staff as necessary. The meal included a soup starter followed by roast chicken, roast potatoes, cabbage and homemade trifle for dessert. The new chef is well motivated and meets each resident daily to find out if they have any preferences in respect of the midday meal. It was noted that fresh ingredients are used with an emphasis on home cooking. The chef is also involved in the meal serving and is able to assess how the meal is received by residents during the meal. The kitchen was seen to be clean and looked to be well managed Hazelbrae DS0000021129.V346337.R03.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Procedures in the home ensure that complaints and any allegation or suspicion of abuse made would be managed appropriately. EVIDENCE: The home has a suitable complaints policy, which is made available to residents and their representatives. The complaint records indicated that there had been one official complaint, which was referred from the CSCI. This complaint has been responded to effectively to the complainant’s satisfaction. Relatives and visiting professionals spoken to confirmed that they were confident that any complaints or concerns that they had would be listened to by the manager and responded to. The home has suitable Safeguarding Vulnerable Adults (Adult Protection Procedures) and staff have received training on this subject. Staff had an awareness of adult protection and they had access to a flow chart that indicated what to do if an allegation or suspicion of abuse is made. This could be improved with the relevant contact numbers being included. Hazelbrae DS0000021129.V346337.R03.S.doc Version 5.2 Page 16 Discussion with the senior carer indicated that she would contact the registered manager or the registered homeowners for guidance immediately and she was confident that she would be able to contact them if needed. She also understood the importance of ensuring and securing residents safety as a priority. Hazelbrae DS0000021129.V346337.R03.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents live in a comfortable homely environment that is being improved with general redecoration. Improvements need to ensure all resident safety issues are fully addressed and maintained and include suitable infection control practice. EVIDENCE: Hazelbrae is a converted property that provides a home like environment which residents are able to identify with and were seen to be moving around freely during the unannounced visit. There was evidence that redecoration and improvements to the environment are being progressed, the lounge has been made much lighter and the hallways are now being completed. Hazelbrae DS0000021129.V346337.R03.S.doc Version 5.2 Page 18 Although the registered manager checks the environment monthly and identifies area that need attention timescales for attention are not addressed in a planed way and this needs to be clearly established. The tour of the home with Mrs Detheridge confirmed that on the whole the home was reasonably well maintained although it was noted that two radiator guards were broken and Mr Detheridge said that he would ensure that these were repaired as a priority. The standard of cleanliness was good and there is a cleaner working in the home each day. The home has now stopped all smoking in the home with staff having to go outside to the garden if they want a cigarette. A staff member commented on how this had improved the environment for all the residents and the one resident that used to smoke has now stopped asking for cigarettes. Resident’s benefit from the use of varied communal areas that include a lounge conservatory and separate dining room on the ground floor. There is a garden area that is accessed via the conservatory this has been improved since the last inspection and now provides attractive out door space. The home is not designated to provide a service to people with physical disabilities as the stairs and other access arrangements would make it unsuitable for residents with a permanent restricted mobility. Access to the first floor is via stairs or a chair lift, further steps are found upstairs. Accommodation within the home for staff is limited and the only office facility is situated in the basement very separated from the home. The home’s laundry is sited away from food preparation areas and suitable hand washing facilities were found throughout the home. The washing machines are domestic in style and do not have a sluice cycle and it was noted that one of these machines was not operational at the time of the inspection. Mrs Detheridge said that this machine was to be replaced and she was reminded that the current practice in the home of hand sluicing soiled linen was poor practice and an appropriate machine with a sluice cycle should be purchased. Contact with the registered manager following the inspection confirmed that the home was purchasing a washing machine with a suitable sluice cycle. The home needs to establish clear infection control procedures to ensure safe practice in the home. Hazelbrae DS0000021129.V346337.R03.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are having their needs met by suitably trained staff although the staffing levels need to be constant and reflect the level of activity in the home. Residents are protected by the home’s recruitment policy and practices. EVIDENCE: At the time of this inspection visit there was 15 residents living in the home, and on the day of the unannounced inspection the staffing arrangements were found to be enough to meet the care needs of the residents and time was available in the afternoon for some activities. The staffing on this day included two carers throughout the day with a cook and a cleaner in the morning and an extra person to provide activities and complete the laundry and kitchen duties between the hours of 15.00 to 18.00 is available four days a week. The registered manager would normally also be working in the home however her hours were not replaced while she went on holiday. The nights are staffed with one carer and one sleeping carer. Hazelbrae DS0000021129.V346337.R03.S.doc Version 5.2 Page 20 Discussion with staff confirmed that residents are up and dressed for breakfast at 08.00. It was unclear if this was due to resident preference or in response to the staffing arrangements, as resident’s preferences on this matter are not recorded. Staffing levels must be kept under constant review to ensure staff are available to meet all residents care needs and preferences. One contact with a relative indicated that afternoons could be very busy and that supervision in the lounge was difficult if staff were busy with residents due to agitation or personal needs. Staff spoken to felt the staffing arrangement were satisfactory and one carer said that she had been concerned in the past regarding the staffing in the afternoon and when she raised this with the manger extra time was made available to allow for extra supervision of residents. Although the weekends and Wednesdays remain without any extra staffing care staff said that this was currently satisfactory. Recent staff recruitment has relieved pressure on the regular staff working extra hours to cover any staffing shortfalls. Feedback from surveys and contact with residents visiting relatives and social/health care professionals was very positive about staff and comments received included ‘Staff are responsive to her advice the care they provide is good and their knowledge and understanding seems to be appropriate they are always welcoming and understanding’ ‘ nothing is too much trouble for the staff they are very caring and understanding’ ‘The staff are all very good and care for my father well’. The recruitment practice in respect of three staff members were reviewed and found to be full and robust, and the records checked included an application form, two references and the necessary Protection Of Vulnerable Adults and Criminal Records Bureau checks had also been obtained. Staff training is well organised and the manager uses a matrix to organise and record the training provided and attended. Contact with staff confirmed that staff training is well promoted with staff able to attend all the necessary training. Staff records confirm that there is a commitment to train staff so that they achieve a National Vocational Qualification in care level 2. Hazelbrae DS0000021129.V346337.R03.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 37 and 38 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home was found to be managed in an open and friendly manner. Systems are in place to safe guard resident’s financial interests and to monitor and demonstrate the quality of care and services in the home. The health, safety and welfare of residents and staff are generally promoted and protected although further attention is needed regarding general safety checks and risk assessment. EVIDENCE: Hazelbrae DS0000021129.V346337.R03.S.doc Version 5.2 Page 22 The home’s manager has substantial relevant experience and has completed relevant care and management qualifications. At the time of the inspection visit to the home the manager was on holiday and a senior carer was in charge of the day-to-day running of the home in her absence. She confirmed that she was able to contact Mr and Mrs Detheridge for support at any time. Feedback from all sources confirmed a confidence in the registered manager, she is well respected by the staff in the home who feel comfortable raising any issue with her and feel supported in their training and development. The home is using questionnaires on a six monthly basis to gain residents and their representatives views on the home and service it provides. Once these are returned they are discussed at a management meeting and if individual issues have been identified the manager responds to these on a personal basis. The audit of the responses and action taken by the home is documented and made available to interested parties in the service users guide/statement of purpose. Mrs Detheridge advised the inspector that the arrangements for dealing with resident’s monies have been reviewed since the last inspection and now includes receipting for the receipt and use of all money. A procedure is now in place and the number of residents personal allowances held on behalf of residents has been reduced. As the registered manager has sole responsibility for this money the inspector was not able to check the arrangements in place. It was recommended that an audit is implemented of the procedures and practice in relation to the monies held on behalf of residents. Although the home has varied policies and procedures these need to be reviewed and updated on an annual basis and to be organised in such a way to ensure staff are able to access and use them. Mr Detheridge the homeowner deals with all maintenance and health and safety issues in the home. A selection of safety certificates were seen and included a current electrical installation safety certificate and gas boiler certificate. It was again noted that a thorough examination of the chair lift had not been completed. Although the environmental risk assessments have been improved they did not identify the broken radiator guards or the large windows in room 8 and 9. Mrs Detheridge was made aware of the possible risks associated with the large windows and agreed to assess these. It is recommended that the Environmental Health Officer is contacted for advice on Health and safety issues in the home. Hazelbrae DS0000021129.V346337.R03.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 2 2 Hazelbrae DS0000021129.V346337.R03.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14(1) Requirement Timescale for action 01/11/07 2. OP26 13(3) That if an admission is thought to be appropriate the home confirms in writing that having regard to the assessment made that the home can meet those needs to the prospective resident or their representative. That the infection control 01/11/07 practice in the home is reviewed and improved in respect of the sluicing of dirty laundry. (Outstanding from last inspection with a completion date of 01/02/07). That all the homes policies and 01/12/07 procedures are updated to reflect current practice and are accessible to staff for their use. That a thorough examination of 01/11/07 the chair lift is completed on a six monthly basis. (Outstanding from last inspection with a completion date of 01/12/06 That the environmental risk assessments are expanded to cover all areas of risk inside and DS0000021129.V346337.R03.S.doc 3. OP37 24 4. OP38 23(2)13(4 ) 5. OP38 13(4) 01/11/07 Hazelbrae Version 5.2 Page 25 outside the home and actioned as necessary. (Outstanding from last inspection with a completion date of 01/12/07) 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. 4. 5. 6. 7. Refer to Standard OP8 OP9 OP12 OP7 OP19 OP27 OP35 OP8 Good Practice Recommendations That a nutritional screening tool is used on all residents and incorporated into the plan of care. That suitable storage facilities are provided for controlled drugs. That clear criteria guidelines for medicine prescribed on a ‘when require’ basis are provided. That the social and psychological care needs of residents is fully assessed and incorporated into the plan of care That the programme of routine maintenance and renewal of the fabric and redecoration is further formalised to identify when improvements are to be made. That the staffing levels and skill mix within the home is kept under review and is changed to meet the needs of residents. That an auditing system is established in order to measure how resident’s monies are being dealt with. That the local Environmental Health Department is contacted for advice on Health and safety matters. Hazelbrae DS0000021129.V346337.R03.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Hazelbrae DS0000021129.V346337.R03.S.doc Version 5.2 Page 27 - 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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