Inspection on 25/04/07 for Hazeldene Nursing Home

This inspection was carried out on 25th April 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

Hazeldene Nursing Home 08/05/06

Hazeldene Nursing Home 27/02/06

Hazeldene Nursing Home 03/11/05

Hazeldene Nursing Home 06/09/05

Hazeldene Nursing Home 22/09/04

Hazeldene Nursing Home 03/06/04

Hazeldene Nursing Home 03/03/04

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

CARE HOMES FOR OLDER PEOPLE Hazeldene Nursing Home 84 Poole Road Darnall Sheffield South Yorkshire S9 4JQ Lead Inspector Janice Griffin Key Unannounced Inspection 07:45 25th April 2007 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 DS0000021784.V331722.R02.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. DS0000021784.V331722.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hazeldene Nursing Home Address 84 Poole Road Darnall Sheffield South Yorkshire S9 4JQ 0114 242 5757 0114 242 1312 none None S & S Health Care 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) Mrs Susan Horne Care Home 60 Category(ies) of Dementia - over 65 years of age (60) registration, with number of places DS0000021784.V331722.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th May 2006 Brief Description of the Service: Hazeldene is a 60-bed home for older people. It is in a residential area of Sheffield with good access to public services and amenities (e.g. bus services, shops, pubs, etc). It is over two floors both serviced by a lift. All the bedrooms are single and there are a suitable number of lounges and dining rooms. The gardens are landscaped and it has a small car park. A range of information including how to obtain a copy of the last inspection report was available on the notice board in the entrance to the home. The weekly fees are: £448 for nursing and £348 for residential care. This information was provided on the 26th March 2007. The home charges extra for chiropody, toiletries, clothing, telephone, holidays and hairdressing. DS0000021784.V331722.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out from 7.45 am to 14.30 p.m. Three people who use the service, two relatives, six staff, including the manager on duty, were spoken to as part of the inspection process. Comment cards were sent to people who use the service, staff and professional visitors one was returned from each group all made positive comments on all aspects of the service provided. A number of records were examined and several areas of the building were inspected. The inspector was pleased to note that throughout the inspection staff interacted positively and sensitively with the people who use the service who were obviously comfortable and at ease in the company of staff. The inspector would like to thank the people who use the service, the manager, the professional visitor, the relatives and staff for their commitment to the inspection process. No complaints have been made about this service since the last random inspection undertaken on the 31st October 2006. What the service does well: The people who use the service said that they generally felt well cared for by the staff and they were treated with respect and kindness. There was a relaxed atmosphere in the home; the staff had taken care to ensure that the people who use the service were helped with all aspects of their personal care; the people who use the service were clean and well dressed, they thought that the food was ‘very good’ and there was plenty of choice available. The relatives and staff said the care provided at this home was good. Routines appeared to be relaxed, the people who use the service said that they could get up when they wished and go to bed at a time that suited them. They also confirmed that they were able to talk to the manager and staff whenever they wished if they had any ideas or concerns. Assessments had been made of the people prior to them coming into the home to ensure that their needs could be met. Healthcare records and contacts with outside professionals were documented in the care plans. The home was clean, tidy and the staff had endeavoured to ensure that all areas were fresh smelling. There was an established programme of staff training and more than 46 of the staff team had obtained their NVQ Level 2. DS0000021784.V331722.R02.S.doc Version 5.2 Page 6 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. DS0000021784.V331722.R02.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 DS0000021784.V331722.R02.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): Standards 3 and 6 were checked. People who use the service experience a good quality outcome in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are fully assessed prior to moving into the home to ensure their needs can be met. They are able to have informal introductory visits to the home at the time of their admission; this makes them feel less anxious. Intermediate care services are not offered at this home. EVIDENCE: Detailed full needs assessments had been completed by the referring social worker before a person is admitted to the home. Families had been involved in the assessment process as appropriate. People who use the service and their relatives said at the time of their admission they were able to have informal introductory visits to the home and they had been provided with a contract containing the relevant information. DS0000021784.V331722.R02.S.doc Version 5.2 Page 9 Records checked and discussion with three people who use the service and two relatives confirmed that their families had been involved in decisions regarding the arrangements. An up to date contract/statement of terms and conditions had been provided to the people who use the service and signed copies were retained on individual files. These clearly detailed the services and facilities provided by the home. DS0000021784.V331722.R02.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): Standards 7,8,9 and 10 were checked. People who use the service experience a good quality outcome in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service receive care and support to meet their physical and emotional needs, this allows them to achieve their individual preferences and personal goals. The care plans had been reviewed on a monthly basis. This allows staff to meet the changing needs of the people who use the service. The systems for the safe administration of medication on the whole were satisfactory. However the omission of some signatures on the MAR sheet does not protects the wellbeing of people living at the home. EVIDENCE: The inspector observed staff interacting in a friendly and positive way towards the people who use the service. Bathroom, toilet and bedroom doors were noted to be closed if people were receiving personal care and staff knocked on doors before entering peoples bedrooms or the bathrooms. DS0000021784.V331722.R02.S.doc Version 5.2 Page 11 Three peoples plans of care were checked. Each set out individual needs and the action required and taken by staff to ensure the needs were met. Discussion with six staff identified that a range of health professionals visited the home to assist in maintaining health care needs. The people who use the service were being weighed on a regular basis. A range of aids to assist them with mobility problems was provided; these included lifting hoists, assisted baths, walking frames and wheelchairs. The care plans had been reviewed on a monthly basis. All care plans detailed the gender of staff that the person wished to support them with their personal care; they also contained details of their religious and cultural needs. People who use the service and their relatives have been involved with production of the care plans. There were systems in place for the safe custody and administration of medication; the containers were all clearly labelled, with prescription information fully legible. All items were for named individuals. There were medication administration (MAR) sheets for each service user; these recorded the type of medication, the dosage and how it was to be administered, however some were not signed to show whether medication had been given or not. There were reasonable stock levels of medication kept in the home. Controlled drugs were safely stored and there were two signatories for the administration of controlled drugs. DS0000021784.V331722.R02.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): Standards 12,13,14 and 15 were checked. People who use the service experience a good quality outcome in this area. We have made this judgement using a range of evidence, including a visit to this service. There is a good range of activities from which people who use the service may choose, for their particular lifestyles. This promotes the wellbeing of service users. People who use the service were supported with maintaining and developing contact with their family and friends, and they said that visitors were always welcome at the home. Which creates a home that people want to visit. A choice of food was offered at breakfast and lunchtime. Some of the people who use the service were being offered special diets on a regular basis. This promotes their rights and choices. DS0000021784.V331722.R02.S.doc Version 5.2 Page 13 EVIDENCE: The aims and objectives of this home reinforced the importance of treating people with respect. The people who use the service and two relatives confirmed that staff were extremely supportive. Staff confirmed that they were encouraged to support the people who use the service with discovering how to enjoy social situations and activities. The people spoken with said that they could have visitors whenever they wished. There are a number of lounges and small quiet sitting areas if the people who use the service wish to see their visitors outside of their rooms. The files contained information about any special dietary needs and the people who use the service had been weighed on a regular basis if this was felt to be necessary. Those people, who were able to say, said that the food was good. The inspector observed breakfast and lunch the food provided was of good quality, well presented and a good choice of food was offered. Ten people were receiving special diets. Special cutlery and crockery was provided for those service users who had difficulty using knives and forks. DS0000021784.V331722.R02.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): Standards 16 and 18 were checked. People who use the service experience a good quality outcome in this area. We have made this judgement using a range of evidence, including a visit to this service. The people who use the service and relatives are confident that their views are listened to and acted upon. Policies, procedures and staff training are in place to protect people who use the service from abuse and harm. EVIDENCE: In June 2006 a complaint was made to the CSCI that a person in the home had fallen twice and staff had failed to notify relatives of this. The complaint that relatives were not promptly notified was upheld. As a result disciplinary action against a member of staff was taken and a training programme was put into place for that individual. The manager was asked to ensure that all staff follow the home’s policies and procedures. The provider took the following action to address the issues: • • A new system to audit accidents and compile risk assessments had been introduced since the inspection. Staff had been instructed to ensure GPs were called if a service user became ill. DS0000021784.V331722.R02.S.doc Version 5.2 Page 15 The provider had appointed a person to visit the home on a weekly basis to audit the service and how the home was being managed The complaints procedure was available for people who use the service, visitors, relatives and staff. The manager on duty confirmed that this would be available in alternative formats and languages should this be requested. The people who use the service and two relatives spoken to said that they knew that they could complain if they were not happy about anything and that they felt able to discuss any issues or concerns that they may have with the manager and staff. They also said that staff were always available and that they were encouraged to talk about anything that troubled them or caused them anxiety. Since the last random inspection no complaints have been made about this home. The staff had received training on recognising and dealing with abuse. Staff had been made aware of the action to take in dealing with third party information. DS0000021784.V331722.R02.S.doc Version 5.2 Page 16 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): Standards 19 and 26 were checked. People who use the service experience a good quality outcome in this area. We have made this judgement using a range of evidence, including a visit to this service. The people who use the service live in a spacious, clean and comfortable home with furniture and equipment available, both communally and individually, to meet their needs. This creates a home that people like to live in. The owners are currently refurbishing parts of the home. This should improve the quality of the environment for the people who use the service. Lockable facilities should be provided in all bedrooms to allow the service users to keep valuable possession in a secure place. The hygiene standards were not sufficient to protect the health of the people who use the service. DS0000021784.V331722.R02.S.doc Version 5.2 Page 17 EVIDENCE: All the people interviewed said that the rooms were very clean. At least three bedrooms were checked, all were very homely, highly personalised and contained a range of furniture, including chairs, bedside tables and suitable storage. Most had photos and ornaments. The lounge areas were spacious and there was a quiet lounge for those who preferred not to sit in the area with the TV on. There were other areas around the home where people who use the service could sit or take visitors if they did not wish to use their rooms. Each floor had a number of toilets and bathrooms and assisted baths were provided for those people with mobility problems. Toilets were easily accessible as they were close to lounge and dining areas. All the toilets had been adapted for people who use the service with physical disabilities and a good supply of equipment was also available for those people. Two refuse bins were not fitted with lids and some bedrooms did not have a lockable facility. The appropriate seating had been provided in the garden for those wishing to sit outdoors whenever the weather permitted. DS0000021784.V331722.R02.S.doc Version 5.2 Page 18 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): Standards 27,28,29 and 30 were checked. People who use the service experience a good quality outcome in this area. We have made this judgement using a range of evidence, including a visit to this service. The staff team were experienced with a good knowledge of the needs of the people who use the service, enabling them to support the people in maintaining their independence. Staff and the people who use the service said that the staffing levels were always good. Appropriate checks had been made on all the staff; this ensures that vulnerable people are protected. The home had a training and development plan and all staff had completed a range of training relevant to their role. 46 of the staff are trained to NVQ level 2. This shows the providers commitment to ensuring they reach the required 50 in the next few months. EVIDENCE: All the people who use the service who were able to clearly express themselves said that they felt that they were well looked after by the staff and that there were ‘usually’ enough people on duty. They said that the staff worked very hard and described them as “very caring, kind and understanding”. DS0000021784.V331722.R02.S.doc Version 5.2 Page 19 Staff were approachable and sensitive to the needs of the people who use the service and were able to communicate effectively with each person. Three staff files were checked; the files demonstrated that the recruitment processes had been followed as required by the Care Homes Regulations. Criminal record checks had been done for all three staff. Two references had been obtained and no gaps were noted in staff’s employment history. Staff spoken to had an understanding of the home’s fire procedures; they had received training on moving and handling, fire, food safety and infection control. Staff files checked and discussions with four staff and the manager confirmed that all staff had completed detailed induction training. 46 of the staff team were qualified to NVQ level 2. Staff were being formally supervised at the frequency required to fully ensure individual staff development and the monitoring of care practices DS0000021784.V331722.R02.S.doc Version 5.2 Page 20 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): Standards 31,33,35 and 38 were checked. People who use the service experience a good quality outcome in this area. We have made this judgement using a range of evidence, including a visit to this service. The people who use the service benefit from a well run home with an effective staffing structure where quality monitoring is ongoing to ensure that people who use the service views underpin the running of the home. Records were in the main up to date and well ordered to ensure the best interests of the people who use the service. All records were available for inspection up to date and securely stored. A safe environment was not provided in all parts of the home. This does not protect the health and welfare of the people who use the service. DS0000021784.V331722.R02.S.doc Version 5.2 Page 21 EVIDENCE: The manager and staff have worked hard recently to improve the service and provide an increased quality of life for the people who use the service. The manager has a job description that clearly defines her roles and responsibilities and staff were aware of her role. Staff said she was committed to ensuring that the home provides a high standards of care, she completes regular internal audits on all aspects of the service provided by the home. Staff spoken to had an understanding of the home’s fire procedures; they had received training on moving and handling, fire, food safety and infection control. There was a quality assurance system, which sought the views of of the people who use the service and relatives. The responsible individual visits the home on a regular basis. No fire exits were blocked but hazardous substances were insecurely stored. The staff handle money on behalf of some service users, account sheets were kept, receipts were available for all transactions and a second individual witnesses financial transactions. An outside auditor had audited the accounts. All records were available for inspection up to date and securely stored. DS0000021784.V331722.R02.S.doc Version 5.2 Page 22 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 2 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 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 DS0000021784.V331722.R02.S.doc Version 5.2 Page 23 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 OP9 Regulation 13 (2) Requirement When medication is administered to people who use the service it must be clearly recorded to ensure that the people receive the correct levels of medication. This requirement has been outstanding since October 2006. 2. OP19 16 (2) (l) A lockable facility must be provided in each bedroom. To give the people who use the service a place to keep their valuables securely stored. This requirement has been outstanding since September 2004. 01/08/07 Timescale for action 25/04/07 3. OP26 23 (2) (d) Refuse bins must be fitted with secure lids, to ensure that the hygiene standards at the home protect the people who use the service. 31/05/07 DS0000021784.V331722.R02.S.doc Version 5.2 Page 24 4. OP28 18 (1) (a) 5. OP38 12 (1) (a) A minimum of 50 of the staff must be trained to NVQ level 2. This will ensure that the staff have the correct training to adequately perform their duties. Hazardous substances must e kept in a secure place at all times. To minimise the risk of accidents to people who use the service. 31/12/07 25/04/07 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 DS0000021784.V331722.R02.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 DS0000021784.V331722.R02.S.doc Version 5.2 Page 26 - 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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