Inspection on 12/01/06 for Hazeldene

This inspection was carried out on 12th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hazeldene 31/07/06

Hazeldene 28/09/05

Hazeldene 28/02/05

Hazeldene 06/09/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Hazeldene 1 Dunbar Avenue Norbury London SW16 4SB Lead Inspector Claire Taylor Unannounced Inspection 12th January 2006 10:00 Hazeldene DS0000028107.V276864.R01.S.doc Version 5.1 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 Hazeldene DS0000028107.V276864.R01.S.doc Version 5.1 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 Adults 18-65. 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. Hazeldene DS0000028107.V276864.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Hazeldene Address 1 Dunbar Avenue Norbury London SW16 4SB 020 8679 1462 020 8679 1462 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) Mr Jacob Lee Mr Jacob Lee Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Hazeldene DS0000028107.V276864.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th September 2005 Brief Description of the Service: Hazeldene is a five bedded small care home registered with the Commission for Social Care Inspection to cater for young adults with a learning disability. Situated in a residential street in Norbury, the home is well placed for public transport links to local amenities and shopping. There are five single bedrooms with one located on the ground floor. Communal areas consist of a spacious lounge, dining area and rear garden with paved area. Sufficient numbers of bathroom and toilet facilities are located near service users bedrooms and communal areas. The proprietor of the home, Mr Cliff Lee, is also the registered manager for the home and works most days. Hazeldene DS0000028107.V276864.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that began at 10.00am and lasted just over four hours. One member of was on duty and the registered manager / provider, Mr Cliff Lee, facilitated the inspection process. None of the four service users were available to comment on this occasion. One service user had moved on since the last inspection so the home had one vacancy. Time was spent examining records, talking to staff, the manager and a brief tour of the premises took place. The focus of this inspection was to monitor compliance with previous requirements and recommendations. The home received a positive report for the previous inspection (September 2005) and has once again showed consistency in its application of the National Minimum Standards as well as a commitment to improve upon standards. All key standards were assessed at the home’s previous inspection and the reader is therefore referred to that report should they require any further information. What the service does well: What has improved since the last inspection? Recruitment practices are more securely managed so that staff are vetted correctly for their suitability to work with vulnerable adults. Completed CRB and POVA checks have been obtained for all staff working in the home. One senior staff has completed accredited medication training and plans were in place for others to attend. Record keeping has improved in some areas. I.e. Notifiable events such as service users’ accidents or incidents are now being reported to the Commission. Service users risk plans have been reviewed to reflect any changing needs. This means that staff have up to date information on how to minimise the risk of potential harm for service users whilst maintaining their independence. Home improvements have included the purchase of a new cooker and replacement curtains fitted throughout. Hazeldene DS0000028107.V276864.R01.S.doc Version 5.1 Page 6 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. Hazeldene DS0000028107.V276864.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hazeldene DS0000028107.V276864.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 5 The home’s Statement of Purpose and Service User’s Guide need to be reviewed and updated so that prospective service users and their representatives are provided with the correct information they need to make an informed decision about whether or not to use the service. Written contracts need to be provided to each service user to ensure that service users are aware of their rights and responsibilities to live in the home and likewise, the home’s duty of care (its terms and conditions). EVIDENCE: A Statement of purpose and guide is in place but now needs revising to accurately reflect the services being provided by the home. There are also issues about the admissions procedure, including that of information, which need to addressed and resolved. The home had admitted a service user for a short time due to temporary breakdown of their family placement. This is considered as respite care admission and the home must ensure that its stated purpose reflects such arrangements. The admissions procedure therefore needs revising. Up to date details about the staff experience and qualifications also need to be included. In addition, the document makes reference to the Registered Homes Act 1984 which is not relevant to current legislation. The provider is therefore required to revise the Statement of purpose and this should be undertaken in consultation with the service users currently living at the home. Although service users have local authority contracts that outline the terms and conditions of occupancy, each individual needs to be provided with a copy of the home’s own contract. Hazeldene DS0000028107.V276864.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 and 9 Care plans for service users are generally well maintained although reviews need to be carried out more frequently to evaluate whether the home is meeting a person’s assessed needs. Service users are provided with the necessary support to take risks so that independence is maximised as far as possible. EVIDENCE: Comprehensive care plans are generated from initial and ongoing assessments and liaison with relevant specialist services as needs were identified. This provides staff with detailed information that enables a continuity of care to be maintained. All individual plans of care were sampled and each contained relevant health and social care information, daily records, involvement with healthcare professionals, an action plan and regular reviews that demonstrated involvement, consultation and agreement of each service user on their plan of care. Overall, plans were being reviewed regularly and involved relatives and other professionals although one service user is now due a review meeting to ensure that any changing needs are identified and addressed. It is acknowledged that care management attendance at some review meetings was reported to be a problem and that the manager has made efforts to arrange a review meeting in conjunction with the placing authority (Croydon). Hazeldene DS0000028107.V276864.R01.S.doc Version 5.1 Page 10 The home has a responsibility however to ensure that a review of service users needs is undertaken at least six monthly. This is important as it provides the service user and relative if appropriate, with assurance that the home can continue to meet their needs. One good practice area for the home to consider is to implement person centred planning. This could make the care plans more accessible and meaningful to some individuals. The manager reported that both he and some staff have undertaken training in this area and that the home has appropriate documentation to enable a more person centred approach to care planning. Service users plans could be developed further to enable some people who have differing methods of communication to be more involved. I.e. Pictures and photos should be included. Service users are encouraged to be independent and staff support individuals to take risks within their daily lives by maximising their potential around selfcare and promoting life skills. As previously required, risk plans had been reviewed to reflect any changing needs for service users. Hazeldene DS0000028107.V276864.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13 and 16 Provision is made so that all service users attend appropriate social activities, day centres and become part of the local community. Staff treat people who live in the home with respect, value their individuality and promote their individual rights. Standards 15 and 17 were assessed as met at the September 2005 inspection. EVIDENCE: The service users all attend work placements or day care services for two days or more each week and were out at their respective centres during this inspection. Two are in paid employment at Crossfield Link centre where they participate in jobs such as printing, domestic tasks and canteen duties. The other two service users attend local day centres. Records showed that service users are offered choices of activities and supported to engage in their preferred interests and hobbies. E.g. baking and colouring for one service user and trips to McDonald’s for another. Two service users travel independently and tend to organise their own activities. Activity plans are flexible so that daily programmes can alter if service users wish to do something different. The home informs service users about activities via meetings, informal discussions and the use of a notice board. Hazeldene DS0000028107.V276864.R01.S.doc Version 5.1 Page 12 Hazeldene DS0000028107.V276864.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 20 Suitable arrangements are in place to ensure that service users’ health care needs are identified, planned for and met. The home’s systems regarding medication are well organised to ensure the safety and consistent treatment and support for each service user. Standard 18 was assessed as met at the September 2005 inspection. EVIDENCE: Information relating to personal and healthcare needs, including both routine and one off health interventions remain well recorded. Care plans and specific strategies identify individual and specialist needs, which also reflect any changing needs. Detailed records were in place and involvement with specialist services highlighted where necessary. E.g. regular medication reviews and physiotherapy services for some individuals. Service users are supported to attend regular health checks, outpatient appointments and other medical appointments as required. The manager reported that one service user’s health needs were under review due to some deterioration in mobility. Records in the service user’s care plan reflected this and that the home shows diligence to monitor individual healthcare needs. Medication practices continue to be well managed and the previous requirement addressed concerning staff training. I.e. one senior staff has completed accredited medication training and plans were in place for others to attend. Hazeldene DS0000028107.V276864.R01.S.doc Version 5.1 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Procedures for dealing with complaints are in place so that service users and their relatives can be confident that their views will be listened to and acted upon. Robust systems are in place to maximise protection for the people who live there although staff should receive more training so that they have a better understanding of preventing abuse and service users are more fully protected. EVIDENCE: A clear complaints procedure is conspicuously displayed in the home and has been formatted with symbols and pictures to make it more accessible to those service users who cannot read. Informal concerns raised by service users are addressed through discussion with staff on a day- to- day basis and at regular service user meetings. A log of complaints is kept in a book and there have been no complaints about the home. Policies and procedures are in place to safeguard service users from abuse including whistle blowing, management of service users money and financial affairs, dealing with physical aggression and the use of restraint as a last resort. As highlighted in previous inspection reports, two members of the current staff team have attended formal training on adult protection through the Local Authority. The provider is now required to ensure that the remaining staff receive such training. Details about how to access abuse training through the local adult protection team were discussed with the manager. Service users’ financial records indicated that they are supported to be as independent with their finances as possible and for those who require support; robust systems are in operation to protect their financial interests. Hazeldene DS0000028107.V276864.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 The home is maintained, decorated and furnished to a high standard which provides service users with comfortable surroundings in which to live. Facilities are clean, safe and homely. EVIDENCE: On this occasion, only the communal areas were viewed, as service users were not in the home. As at previous inspections, the standard of décor and cleanliness throughout Hazeldene remains highly maintained. Further home improvements have been carried out such as the replacement of curtains throughout and a new cooker purchased. Hazeldene DS0000028107.V276864.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35 Service users benefit from a small but stable and knowledgeable staff team, who are provided with the necessary training and guidance to support their needs. Staff are given the information about what is expected of them and how to do their work properly although staff meetings need to be held more regularly. Recruitment practices are more securely managed to maximise protection for the service users. EVIDENCE: Due to the home’s small size, service users benefit from a family type environment and close support from a staff team who remain unchanged since the last inspection. The owner/manager works most days and is available on call in the event of an emergency. Discussions and records showed that staff respect service users’ individuality as well as demonstrate an understanding of their specific needs. In addition, the home maintains good links with other professionals and service users relatives. Four other care staff are employed at the home and since the last inspection, two part time staff have been appointed subject to the completion of satisfactory checks. The manager explained that he was awaiting the return of the CRB / POVA checks before they can start. The home’s recruitment practices therefore ensure that staff are vetted correctly so that service users are safeguarded from people who should not be working there. Rotas showed that a consistent core team of agency staff are used to cover vacancies, meaning that there is familiarity for the service users. Two staff files were viewed and contained all the necessary Hazeldene DS0000028107.V276864.R01.S.doc Version 5.1 Page 17 documentation as required in the Care Homes Regulations 2001. Comprehensive systems are in place to ensure staff receive relevant training and guidance during their orientation to the home and consequent career development. Three staff have completed their NVQ2 training. Staff meetings need to be held at more regular intervals, as there had only been one in the last six months. Hazeldene DS0000028107.V276864.R01.S.doc Version 5.1 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39 and 42 As previously required, the home’s quality assurance system still needs improving to ensure that quality of care is regularly appraised and the home is meeting its objectives. Overall, health and safety practices are well observed. To ensure unnecessary risks to the health and safety of the service users and staff are minimised, risk assessments of the premises still needs to be reviewed. Standard 37 was assessed as met at the September 2005 inspection. EVIDENCE: At the two previous inspections, the home was required to implement a quality assurance system and an annual development plan, with both involving service users. Questionnaires were offered to service users in January 2005 although the views of their relatives and other interested parties has yet to be sought. Once these are obtained this information can be included in the annual development plan. This then can be used as the basis of a quality assurance system. As this has not commenced, the requirement remains in force. Accurate records are kept for accident and incident reporting. As required at the last inspection, the home now keeps the Commission appropriately Hazeldene DS0000028107.V276864.R01.S.doc Version 5.1 Page 19 informed of any accidents or incidents that affect the service users well being. Maintenance and servicing records were not examined on this occasion as they were checked at the last inspection and all up to date. Risk assessments covering safe working practices have been completed for the premises although as previously identified, they still need to be expanded upon to clearly identify what action or measures are in place to minimise risks. Aside from this, the home was found to be safe, and the welfare of service users and staff promoted. Hazeldene DS0000028107.V276864.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. 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 2 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 X 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 3 X X X 2 X X 2 X Hazeldene DS0000028107.V276864.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? Yes- 2 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 YA1 Regulation 6(a) Sch 1 Requirement The registered provider must revise the home’s Statement of Purpose so that it accurately reflects the services provided in the home and the process for admissions. Each service user must be provided with a copy of the homes contract. Service users plans must be reviewed at least every six months. An appropriate review meeting is held for service user C.L. involving the appropriate care manager to ensure that any changing needs are assessed and actioned. All staff must receive training on the Protection of Vulnerable Adults, with records to evidence this kept in the home. Staff meetings need to be held at least six times a year with minutes of discussions and outcomes maintained. A written annual quality assurance development plan needs to be developed for the home. (Requirement now outstanding from 31.10.04) DS0000028107.V276864.R01.S.doc Timescale for action 31/03/06 2. 3. YA5 YA6 5(1b&c) 14(1)(d) (2)(a) 15 31/03/06 31/03/06 4. YA23 13(6) 18 19 21(1) 30/04/06 5. YA33 31/01/06 6. YA39 24 31/03/06 Hazeldene Version 5.1 Page 22 7. YA39 24 8. YA42 13(4) 15(1) Sch.3, 3q The views of family members, friends / representatives and other interested parties should be sought to ensure the home is meeting its aims, objectives and statement of purpose. (Previous Recommendation (28/02/05) now made as requirement) Risk assessments concerning safe working practices must be more detailed to clearly outline what measures are in place to reduce identified risks. (Requirement now outstanding from 31.11.04) 31/03/06 31/01/06 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 YA6 YA6 Good Practice Recommendations That the home implements Person Centred Planning so that service users care plans are more individualised and meaningful to them. Some service users cannot use verbal communication and the home should therefore consider ways to improve its communication methods for these particular individuals. I.e. service user plans written in a format that they can understand. E.g. pictorial, audio or graphic. (Repeated from September 2005 inspection) Hazeldene DS0000028107.V276864.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Hazeldene DS0000028107.V276864.R01.S.doc Version 5.1 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. 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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