Inspection on 21/04/05 for Hazelbrae

This inspection was carried out on 21st April 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 19/09/05

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 James Houston Unannounced 21 April 2005 9:00 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 V222282 190405 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Hazelbrae Address 76 St Saviours Road St Leonards-on-Sea East Sussex TN38 0AR 01424 425080 None None Crowhurst Care Limited 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 Susan Straughan Care Home 15 Category(ies) of Dementia (DE) 15. registration, with number of places Hazelbrae H59-H10 S21129 Hazelbrae V222282 190405 Stage 4.doc Version 1.20 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 will be aged sixty-five (65) or over on admission. Date of last inspection 28 September 2004 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 approximately one mile away. Service users 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 service users. Hazelbrae is registered to provide residential and social care to fifteen (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 V222282 190405 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over a day on 21st April 2005. It involved pre-inspection file reading and preparation, and the inspection itself lasted six and a half hours. The home’s provider, the manager, four staff and four visiting family members or friends of service users, eight service users and a visiting community nurse were spoken to during the course of the inspection. A tour of the building was undertaken, and files, records and policies were read. There have been no additional visits to the home since the last inspection. The home’s former deputy manager Mrs Susan Straughan has become the home’s registered manager since the last inspection. What the service does well: What has improved since the last inspection? The owners and new manager have addressed fully the requirements and recommendations made at the last inspection. Care management assessments have been obtained on all new service users. Care planning has thereby been improved. The home’s statement of purpose has been updated, giving better information to service users, prospective service users and their families. Rotting woodwork at the rear has been replaced with new windows, and it was possible to slightly enlarge one bedroom and give it an extra window affording the service user more light and a larger room. Several areas have been redecorated. The tumble drier in the Hazelbrae H59-H10 S21129 Hazelbrae V222282 190405 Stage 4.doc Version 1.20 Page 6 laundry has been vented to the external air, improving the working environment. 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. Hazelbrae H59-H10 S21129 Hazelbrae V222282 190405 Stage 4.doc Version 1.20 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 Standards Statutory Requirements Identified During the Inspection Hazelbrae H59-H10 S21129 Hazelbrae V222282 190405 Stage 4.doc Version 1.20 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 standard(s) 1,3,4, and 6. The registered person makes available to prospective service users and their relatives a Statement of Purpose and Service Users Guide that informs them of how the home operates. New service users are admitted only on the basis of a full assessment undetaken on them. The home was able to demonstrate its capacity to meet the needs of those admitted. EVIDENCE: The home has produced a satisfactory Statement of Purpose and Service Users Guide for service users. Both documents have been subject to revision, and the manager had added the circumstances when emergency admissions would be made, and during the inspection added reference to a double room very marginally under the size recommended. Several files of service users inspected in detail showed that the manager carries out full pre-admission assessments, and for funded clients obtains copies of Care Management assessments. The home was able to demonstrate that it can meet the needs of service users. Interaction observed between staff and service users showed caring and encouragement. Staff interviewed were enthusiastic and knowledgeable. Hazelbrae H59-H10 S21129 Hazelbrae V222282 190405 Stage 4.doc Version 1.20 Page 9 The home does not at present offer intermediate care, nor is it their intention to do so. Hazelbrae H59-H10 S21129 Hazelbrae V222282 190405 Stage 4.doc Version 1.20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8 and 9. The home has comprehensive care plans. The health care needs of service users are met through careful planning and full recording. The medication administration system is suitably maintained. EVIDENCE: Several care plans were inspected at random. They contain thorough care planning documentation and needs assessments that were seen to be completed, reviewed and updated on a regular basis to reflect changing needs. Risk assessments are recorded and updated. Staff confirmed that they base care given on the care plans, and write in records about what they have done. The home operates a key worker system. The home keeps clear records of contacts with and visits by a wide range of health service professionals. The inspector spoke briefly during the inspection to a visiting community nurse who said that the home is caring and committed. Staff said that particular attention is paid to oral hygiene and to service users who are at risk of developing pressure sores. Records showed that service users are weighed regularly. Service users have access to dental and chiropody services and sight and hearing tests. Medicines are securely stored. No service users currently self medicate. The records of drugs administered was inspected and found to be fully recorded. Hazelbrae H59-H10 S21129 Hazelbrae V222282 190405 Stage 4.doc Version 1.20 Page 11 No controlled drugs are held for service users at present but the systems to do so are to hand should the need arise. Staff who administer medicines said that they have had relevant training. Hazelbrae H59-H10 S21129 Hazelbrae V222282 190405 Stage 4.doc Version 1.20 Page 12 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 and 13. Social activities and community contact are well managed and provide interest and activity for people living in the home. EVIDENCE: Staff provide activities for service users who wish to join in, for example memory games and music with movement. Staff confirmed that service users have choice as to food – one service user is vegetarian. Service users can practice religious observance if they wish. Volunteers take out one service user to church from the church. Service users do not go out alone but service users and staff confirmed that family and friends take out several service users. The manager said that she takes out to local places of interest service users who wish to go with her. Service users are free to receive visitors and can see them in private. Visitors said that they are made to feel welcome, and staff said that they see it as part of their role to greet visitors and to offer them a drink etc. Hazelbrae H59-H10 S21129 Hazelbrae V222282 190405 Stage 4.doc Version 1.20 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 standard(s) 16. The home has a satisfactory complaints procdure and records fully any investigations made. EVIDENCE: The home has a complaints policy that explains clearly to service users 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 has kept records which show that the matters were immediately and appropriately dealt with to the satisfaction of the complainant. The Commission has received no complaints for Social Care Inspection. Hazelbrae H59-H10 S21129 Hazelbrae V222282 190405 Stage 4.doc Version 1.20 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 standard(s) 19,20,22,23,25 and 26. The home is maintained to a good standard and offers a warm comfortable environment. EVIDENCE: The provider maintains the home, and was present throughout the inspection. A programme of renewals and redecoration is in progress. Some bedrooms and the hall stairs and landing have been redecorated since the last inspection. A small number of items required attention. The provider dealt during the inspection with a door that did not close onto its stops, and will repair as needed a pane of glass needing attention. A fire risk assessment has been completed recently. Fire safety records showed that fire safety equipment is tested regularly. Fire doors should not be wedged or held open. The environmental health officer visited in February 2005. Two of the recommendations have been met and the third will be addressed shortly. The home’s grounds are safe, tidy and accessible. The home has a dining room and a lounge area with a small adjoining conservatory. These rooms are well decorated and comfortably furnished. Hazelbrae H59-H10 S21129 Hazelbrae V222282 190405 Stage 4.doc Version 1.20 Page 15 The home has a stair lift fitted to assist service users with mobility problems. Grab rails and handrails are fitted as needed, and one of the baths has a hydraulic bath chair for assisting service users. The home has 11 single rooms, and two double rooms. Service users said that they liked their rooms. All rooms have natural ventilation, and are centrally heated. Guards have been fitted to radiators throughout the home. A mixer valve has been fitted to ensure a safe water temperature at all hot water outlets and temperature checks are carried out regularly. The laundry is sited away from food preparation areas, and is well equipped. The tumble drier has now been vented to the external air. Hazelbrae H59-H10 S21129 Hazelbrae V222282 190405 Stage 4.doc Version 1.20 Page 16 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) 27and 29. The needs of service users are met by the numbers and skill mix of staff. The homes recruitment procedures are generally thorough, but full employment history and a writtn explanation of gaps should be sought from persons seeking employment in the home. EVIDENCE: Observation of staff working with service users showed that they are aware of service users’ needs and skilled at assisting service users. Service users said that staff were kind. Family members said that staff are friendly, helpful and welcoming and offer encouragement to service users. Staff turnover was said to be low. A recorded rota inspected showed how many staff were on duty and in which capacity. Staff were present in sufficient numbers to meet the needs of service users. The manager appears on the rota, but does more hours than the rota reflects. This assists her and her staff to meet the needs of service users. There are additional staff at peak hours, and a cook, a cleaner and a laundry assistant. Staff left in charge are aged at least 21. A senior staff member is said to be always on call. The home has a good recruitment procedure, but had not got a sufficiently full employment history and written explanation as to gaps on staff appointed since the last inspection. Evidence was seen that staff have Criminal Record Bureau checks. Hazelbrae H59-H10 S21129 Hazelbrae V222282 190405 Stage 4.doc Version 1.20 Page 17 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) 31,32,34,35, 36,and 37. The former deputy manager was registered as manager in November 2004. The home is running well, and the atmosphere is good. The homes financial procedures and handling of service users monies are satisfactory. Staff receive regular supervision and records are well kept. EVIDENCE: The manager demonstrated that she is undergoing periodic training to update her skills. She is working towards completing her NVQ level 4 in Care and her registered managers award. Staff feel able to put forward suggestions as to how the home is run, and said that there are regular minuted staff meetings. Staff seek the opinions of service users regularly, and stakeholders such as family and health professionals are asked for their views as to how well service users needs are being met. The home has adequate insurance cover and the certificate of insurance was on display on the home. The home has a financial and business plan. This was not inspected on this occasion. The manager Hazelbrae H59-H10 S21129 Hazelbrae V222282 190405 Stage 4.doc Version 1.20 Page 18 confirmed that she keeps a record of all financial transactions. Due to their mental frailty service users do not look after their own finances and their relatives or representatives do this for them. Some personal Spending monies for service users are held, and a record checked at random showed that receipts records and balances are maintained up to date. Staff said that they are supervised regularly and records checked confirmed this. Those records inspected were kept to a high standard. Hazelbrae H59-H10 S21129 Hazelbrae V222282 190405 Stage 4.doc Version 1.20 Page 19 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. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 x COMPLAINTS AND PROTECTION 2 3 x 3 3 x 3 3 STAFFING Standard No Score 27 3 28 x 29 2 30 x 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 3 3 3 3 x Hazelbrae H59-H10 S21129 Hazelbrae V222282 190405 Stage 4.doc Version 1.20 Page 20 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. 2. Standard 24 29 Regulation 2394)(a) 19(1)(b) Requirement Fire doors must not be wedged or held open. A full employment history, together with a satisfactory written explanation of any gaps must be obtained from persons seeking employment. Timescale for action 21 April 2005 21 April 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. Refer to Standard Good Practice Recommendations Hazelbrae H59-H10 S21129 Hazelbrae V222282 190405 Stage 4.doc Version 1.20 Page 21 Commission for Social Care Inspection Ivy House, 3 Ivy Terrace Eastbourne East Sussex 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 V222282 190405 Stage 4.doc Version 1.20 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. 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