Inspection on 22/05/07 for Hazelbrook Christian Nursing Home

This inspection was carried out on 22nd May 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 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

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Hazelbrook Christian Nursing Home Albert Street Horwich Bolton Lancashire BL6 7AW Lead Inspector Mike Murphy Unannounced Inspection 22nd May 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Hazelbrook Christian Nursing Home DS0000068435.V333018.R01.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. Hazelbrook Christian Nursing Home DS0000068435.V333018.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hazelbrook Christian Nursing Home Address Albert Street Horwich Bolton Lancashire BL6 7AW 01204 693175 01204 667344 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) Pindy Enterprises Limited Mrs Hilary Peake Care Home 38 Category(ies) of Old age, not falling within any other category registration, with number (38), Physical disability (3) of places Hazelbrook Christian Nursing Home DS0000068435.V333018.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 38 service users to include:*Up to 38 service users in the category of OP (Old age not falling within any other category), *Up to 3 service users in the category of PD (Physical disability). Date of last inspection Brief Description of the Service: Hazelbrook Christian Nursing Home is located in Horwich town centre, close to the main shopping centre and a range of amenities. A former Methodist church and Sunday school building, it was originally built in 1867 and renovated and refurbished in 1988 to become a care home. The home provides nursing and personal care. There are 32 single rooms and 3 shared rooms. The aim of the home is to provide care in a Christian environment, but people not of the faith are also cared for. There is a small patio for residents’ use and a car park at the rear of the building. The home changed ownership in February 2007. Fees range from £385.00 to £495.00 per week (information provided by the home at the time of this inspection). For further details please contact the home. Hazelbrook Christian Nursing Home DS0000068435.V333018.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection, which the manager did not know was going to take place, is the first conducted since the home changed ownership in February 2007. Whilst the ownership of the home has changed the registered manager has been in post some 18 years. This inspection was conducted 22nd of May 2007 between 1000 and 1500hrs. And included discussion with residents, the manager and staff, inspection of the premises, inspection of records maintained by the home in relation to how residents are cared for, supported and protected. No residents’ relatives were encountered during the inspection but some relatives’ views have been expressed in comment cards returned to the CSCI prior to the inspection and these are reflected in the report. What the service does well: What has improved since the last inspection? What they could do better: Whilst there is generally a sound system of staff recruitment in place the application form that is currently completed by prospective staff needs to be reviewed. The application needs to reflect in detail the applicants work history – including an explanation of any gaps. This helps (along with the other screening measures in place) to ensure that people who care for vulnerable people are suitable to do so. Hazelbrook Christian Nursing Home DS0000068435.V333018.R01.S.doc Version 5.2 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Hazelbrook Christian Nursing Home DS0000068435.V333018.R01.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 Hazelbrook Christian Nursing Home DS0000068435.V333018.R01.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): 3. (standard 6 does not apply to this service) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. No prospective residents are admitted to the home without their care and support needs being assessed appropriately. EVIDENCE: Prior to residents being admitted to the home an assessment of the prospective resident’s needs is carried out in consultation with the resident, their relatives and relevant health and social care professionals such as doctors and social workers. The purpose of such an assessment is to assist the prospective resident (and their relatives) in their considerations of how appropriate a placement at the home would be and enable the nurse conducting the assessment to determine if the home will be able to meet the prospective resident’s needs appropriately. The initial assessment helps to form the basis of the plan of care to be followed following admission to the Hazelbrook Christian Nursing Home DS0000068435.V333018.R01.S.doc Version 5.2 Page 9 home. The 4 residents care records inspected contained detailed pre and post admission assessments. Hazelbrook Christian Nursing Home DS0000068435.V333018.R01.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care provided for residents appears to be suitable and appropriate and is meeting the expectations of residents and their relatives. EVIDENCE: The care records of four residents were inspected. These contained care plans that were initially based on the pre-admission assessment that is referred to earlier in this report. Care plans addressed the physical, psychological, social and spiritual needs of residents appropriately and were evaluated at least monthly. Risk assessments, that seek to protect resident’s health and safety were also recorded in respect of residents skin integrity (assessing the risk of pressure sores), mobility (including the risk of potential falls and fractures, nutrition, including weight monitoring) and other relevant areas were also evaluated at least monthly. Hazelbrook Christian Nursing Home DS0000068435.V333018.R01.S.doc Version 5.2 Page 11 All residents are registered with a local GP and it was evident that all were enabled to access opticians, chiropodists, dentists, district nurses and other specialist services as individual residents needed. Pre-inspection comment cards completed by relatives indicated that they are kept informed of all changes in their relation’s health. The procedures for the receipt, recording, storage, handling, administration and disposal of resident’s medicines were appropriate and safe. The qualified nurses are responsible for all aspects of managing medication in the home. Carers who assist in this process are provided with medicine awareness training. Medication administration records had been completed appropriately. Discussion with residents and staff (and responses in Pre-inspection comment cards completed by residents and relatives) revealed that residents were treated with respect and that their right to privacy was upheld. Comments made included; ‘the staff are very good and take very good care of me’, ‘the nurses and staff always speak nicely to me and get the doctor when I am not well’, ‘I like to stay in my room most of the time and that is not a problem here’. On the day of inspection staff were observed to treat residents with respect, protected their dignity and assisted them appropriately. Hazelbrook Christian Nursing Home DS0000068435.V333018.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were being supported by staff to participate in social activities and are able to retain the ability to make personal choices. There was a general satisfaction with meals provision at the home. EVIDENCE: A record of leisure and social activities provided for and participated in by residents is maintained. This record reflected that activities are varied and include outings on a regular basis. Discussion with residents and staff identified the things residents enjoyed and they also felt they were enabled to participate or not as they chose to do. Activities within the home include craftwork, bingo, board games, reminiscence activities, themed events, musical and film afternoons, and board games. There is a morning service in the home each day. Residents were also of the view that the routines of daily life were as reasonable as possible and it was evident on the day of inspection residents Hazelbrook Christian Nursing Home DS0000068435.V333018.R01.S.doc Version 5.2 Page 13 had either chosen to get up later in the morning, spend time in their rooms or use the communal lounges as they wanted to. Residents and their relatives report no unreasonable restrictions to visiting at the home which take place in communal areas or resident’s bedrooms. Residents are actively encouraged to maintain contact with the local community if they wish. Resident’s indicated that they are encouraged/enabled to retain as much personal autonomy and make personal choices in their daily lives as they can and many have brought a number of personalised items to individualise and personalise their rooms. Meals are cooked on site in the home’s kitchen. Menus are varied and balanced and provide choice. Meals are served in an appropriate dining room. This is an appropriately furnished room that provides a comfortable and pleasant area for residents to have their meals. Some residents either prefer to (or because of the nature of their illness) take their meals in their own room. Residents’ meal times are as reasonable and as flexible as they can be in a communal setting. Lunch was observed on the day of inspection. This was a hot and substantial meal and staff assisted and served residents their meals appropriately. Hazelbrook Christian Nursing Home DS0000068435.V333018.R01.S.doc Version 5.2 Page 14 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and relatives felt comfortable enough to and knew how to make a complaint if they felt it necessary. Written guidance and training arrangements ensure that staff members have a good knowledge of abuse and protection arrangements and safeguards were in place to protect the welfare of residents. EVIDENCE: The complaints procedure was prominently displayed in the home and included details of how to contact the CSCI if it was felt necessary by the complainant. Relatives said (in Pre-inspection comment cards) that any concerns or worries brought to the manager’s attention are responded to quickly and don’t become formal complaints. A complaints log is maintained – there were no entries at the time of inspection. No complaints have been made to the CSCI in respect of the home. Hazelbrook operates protection of vulnerable adults and whistle blowing policies that seek to protect residents. Also Bolton’s Inter agency protection procedure is held on site. Staff spoken to confirmed that they had received adult protection training (this was also reflected in training records maintained by the home) and were aware of the whistle-blowing policy. Hazelbrook Christian Nursing Home DS0000068435.V333018.R01.S.doc Version 5.2 Page 15 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): 19,20 21,22,24,25 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home appeared to be structurally well maintained and provides a pleasant and appropriate environment to accommodate, care for and support residents. EVIDENCE: A tour of the premises during this unannounced inspection revealed that the home was clean and free of malodour. Lounge and dining areas were accessible to all residents, comfortably furnished, suitably lit, homely and warm. WC and bath/shower rooms were appropriately equipped and adapted to meet the health and safety needs of residents. Four bedrooms were inspected on this occasion – these were clean, warm, suitably ventilated, comfortable and appropriately furnished and equipped. All heating radiators were of a low surface temperature variety and the inspector was informed that thermostatic mixer valves regulated hot water temperatures in the home. A Hazelbrook Christian Nursing Home DS0000068435.V333018.R01.S.doc Version 5.2 Page 16 programme of maintenance and refurbishment has been developed and implemented for the year 2007- 2008. Residents spoken to were happy with their environment. Residents are encouraged to bring personal items into the home and this creates a more personalised atmosphere in resident’s own rooms. The garden area is accessible to residents and the inspector was informed there are plans to refurbish this area this year. Appropriate measures to prevent the spread of infection were in place – including adequate hand washing/cleaning facilities, laundry and sluicing arrangements, provision of disposable gloves and aprons for staff, adequate provision of house keeping staff, and appropriate arrangements for the disposal of clinical and other waste. Hazelbrook Christian Nursing Home DS0000068435.V333018.R01.S.doc Version 5.2 Page 17 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff were meeting resident’s needs appropriately, were being appropriately trained and are in the main subject to an appropriate recruitment procedure. EVIDENCE: Inspection of staffing rotas indicated that staffing provision at the home complied with the current minimum requirements that apply to care homes for older people. Discussion with manager and staff at the home indicated that they were of the view that staffing levels were appropriate to meet the dependency levels and needs of resident’s. There is also adequate provision of housekeeping and catering staff at the home. Inspection of 3 staff personnel files revealed that these contained an application form (including health declaration), 2 written references, details of work permits (where applicable), a Criminal Records Bureau check (including a ‘POVA first’ check), proof of identity and evidence of induction training. However the application form that is used needs to be changed to record details of the applicant’s work history (including the requirement to explain any gaps in that history) – doing so helps (along with the other screening measures in place) to ensure that staff who care for vulnerable people are Hazelbrook Christian Nursing Home DS0000068435.V333018.R01.S.doc Version 5.2 Page 18 suitable to do so. This was discussed with the registered manager on the day of inspection. There is a strong commitment to NVQ, mandatory and other training provision for all staff at the home. Training records are detailed and organised and discussion with staff indicated that they are enabled and supported in accessing appropriate training to look after their residents effectively and safely. All staff employed at the home are provided with appropriate induction training. A review of staff training is conducted as part of the regular individual staff appraisal/supervision conducted by the registered manager. Hazelbrook Christian Nursing Home DS0000068435.V333018.R01.S.doc Version 5.2 Page 19 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 and 38. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Hazelbrook is being effectively managed by the very experienced registered manger- a qualified registered nurse with wide experience in general nursing, management and care of the elderly. EVIDENCE: The registered manager is a registered nurse who has the required qualifications and experience and manages the home in such a way that seeks to meet the aims and objectives of the home. Senior nurses and an administrator support the manager in her role. Whilst the home has changed ownership early in 2007 the registered manager has been in post for 18 years. Hazelbrook Christian Nursing Home DS0000068435.V333018.R01.S.doc Version 5.2 Page 20 Discussion with residents and staff indicate that the manager is accessible and operates an ‘open door’ policy that enables any issues to be easily discussed with her. Management policies are effectively implemented and monitored. The inspector is of the view that the home is run in the best interests of the residents and this was confirmed through discussion with residents and staff. The manager operates procedures that seek to ensure the quality of the service provided is good through regular quality questionnaires that seek residents and relatives views on the service provided by the home – and where it is identified as not being up to standard takes appropriate action to rectify the situation. The manager regularly conducts checks of various aspects of systems and procedures operated by the home. The new owners also regularly visit the home and make a written record of these visits. Measures were in place to ensure that residents’ financial interests are safeguarded. Residents are encouraged to control their own money. However where they are unable (or choose not to) personal allowances are managed by the home. The health, safety and welfare of residents and others are promoted and protected. For example staff are provided with regular training and appropriate equipment to ensure resident’s moving and handling needs are met – an example of this would be for a resident who needs to be safely moved with the aid of a hoist. Fire safety training is regularly provided. The recommendations made in 2006 by the fire safety officer are being addressed in relation to his proposed time-table to replace seals to fire doors in the home. Documentary evidence was seen of the fire alarm system/fire fighting equipment and gas and electrical safety inspections/servicing. The premises were secure at the time of this unannounced inspection. Hot water temperatures were controlled and taps were fitted with devices that are intended to prevent burns. The passenger lifts that enable residents and others to access all areas of the home have been serviced as has all hoisting equipment used in the home. All significant events in the home – including accidents and illness and monitoring visits by the home’s owners – are recorded and reported (as required legally) to the CSCI. Hazelbrook Christian Nursing Home DS0000068435.V333018.R01.S.doc Version 5.2 Page 21 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 X X 3 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 3 3 3 X 3 3 3 STAFFING Standard No Score 27 3 28 4 29 2 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 X X 3 Hazelbrook Christian Nursing Home DS0000068435.V333018.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? N/A 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 OP29 Regulation 19 (1)(b) Schedule 2 paragraph 6 Requirement You must confirm to the CSCI in writing that all prospective employees submit a full employment history (as part of their application) together with a satisfactory written explanation for any gaps in employment. Timescale for action 30/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Hazelbrook Christian Nursing Home DS0000068435.V333018.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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 Hazelbrook Christian Nursing Home DS0000068435.V333018.R01.S.doc Version 5.2 Page 24 - 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. 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