Inspection on 03/11/05 for Hazeldene Nursing Home

This inspection was carried out on 3rd November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 25/04/07

Hazeldene Nursing Home 08/05/06

Hazeldene Nursing Home 27/02/06

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 Unannounced Inspection 3rd November 2005 07:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Hazeldene Nursing Home DS0000021784.V261910.R01.S.doc Version 5.0 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. Hazeldene Nursing Home DS0000021784.V261910.R01.S.doc Version 5.0 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 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) S & S Health Care Mrs Susan Horne Care Home 60 Category(ies) of Dementia - over 65 years of age (60) registration, with number of places Hazeldene Nursing Home DS0000021784.V261910.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th September 2005 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. Hazeldene Nursing Home DS0000021784.V261910.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over one day between 7.00 am and 2.15pm. As part of the inspection process three-service users, two relatives and eight staff, including the manager, were spoken to. A number of records were examined and several areas of the building were inspected. The inspector was pleased to note that throughout the inspection all the staff interacted positively and sensitively with each service user who were obviously comfortable and at ease in the company of staff. The inspector would like to thank service users, the relatives, the manager and staff for their commitment to the inspection process. What the service does well: What has improved since the last inspection? Meal times were well organised and staff were noted to interact well with the service users at breakfast and lunchtime. Staff were observed offering service users a good choice of drinks and they took time to sit with the service users when assisting them to eat or drink. The care plans were better-organised and detailed service users nutritional needs and what steps staff should take if service users were losing weight. Service users and staff commented upon the staff group who seemed to enjoy working at the home which resulted in there being a pleasant relaxed atmosphere, described by one service user as being ‘the next best thing to home’. Additional information had been added to service users and staff files to make sure that they meet the standard required. Hazeldene Nursing Home DS0000021784.V261910.R01.S.doc Version 5.0 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 Nursing Home DS0000021784.V261910.R01.S.doc Version 5.0 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 Hazeldene Nursing Home DS0000021784.V261910.R01.S.doc Version 5.0 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 the following standard(s): 3,4,5 and 6. Service users individual needs had been fully assessed prior to their admission, and they had moved into the home once it had been agreed that the home could meet their needs. Service users were able to have informal introductory visits to the home and at the time of their admission had been provided with a contract containing the relevant information. The home does not provide intermediate care. EVIDENCE: Detailed full needs assessments had been completed by the referring social worker for service users admitted to the home. Their families had been involved in the assessment process as appropriate. The manager confirmed that service users were only admitted to the home once they were sure that they could meet their needs. This is good management practice. Service users were able to visit the home for informal visits prior to their admission if they wished. Service users confirmed that this helped them to get to know everyone at the home and made them feel less anxious. Records checked confirmed that service users families had been very involved in decisions regarding the arrangements. Hazeldene Nursing Home DS0000021784.V261910.R01.S.doc Version 5.0 Page 9 An up to date contract/statement of terms and conditions had been provided to service users and relatives, signed copies were retained on individual files. These clearly detailed the fees, including any extra charges, and the services and facilities provided by the home. Hazeldene Nursing Home DS0000021784.V261910.R01.S.doc Version 5.0 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 the following standard(s): 9 and 11. The procedures in place to ensure the safe management of medication need to be improved. Service users said they were treated with respect and that their right to privacy was upheld. The home had a policy on death and dying. EVIDENCE: Systems were in place to ensure the safe recording of medication, however it was noted that medication for external use was insecurely stored in some bedrooms. Records were kept of medication received into the home and returned. Service users were well dressed and each had their own preferred choice of dress, hairstyle and appearance. Any specialist equipment required had been provided and the levels of support required by each person had been regularly reviewed. This ensured that their needs in relation to dignity, choice and independence were met. Measures were in place to ensure that any issues relating to weight, medication or other health problems were identified and dealt with as a priority. Hazeldene Nursing Home DS0000021784.V261910.R01.S.doc Version 5.0 Page 11 Staff interviewed said that they would always sit with service users at the time of death if family were not available. They also said that every effort would be made to ensure that the service users receive appropriate medical attention and pain relieve. Staff would attend the funeral of service users. This allowed the staff to pay their respect to the service user and family and friends. Hazeldene Nursing Home DS0000021784.V261910.R01.S.doc Version 5.0 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 the following standard(s): 12 and 15. Service users were able to maintain and develop their social, emotional, communication and independent living skills. Service users were provided with regular opportunities to engage in appropriate activities, based on their personal preferences. Service users had varied weekly activity programmes and some service users had developed and maintained links with their local community. The daily routines were flexible and promoted individual choice and independence. The service users said the meals provided were in the main wholesome, appealing and well balanced. EVIDENCE: Service users said that staff encouraged and supported them with their chosen activities in the home and in the local community. All spoken to confirmed that staff encouraged them to be independent. Service users said they liked how they spent their time and if they wanted to do anything different they would discuss this with the manager or at their review meetings. All service users said they could choose what they wanted to do and who they wished to spend time with whilst they were at the home. Staff observed were respectful and attentive to the needs of each individual with whom they had obviously developed positive relationships. Relatives confirmed that they could entertain the service users in their room if they wished. Hazeldene Nursing Home DS0000021784.V261910.R01.S.doc Version 5.0 Page 13 They also said they were able to see visitors in private and that visitors were made welcome, encouraging the maintenance of contact with family and friend, which creates a home that people want to visit. The service users said the food was “good and there was always plenty of it”. Three meals were offered each day and snacks and drinks were provided inbetween meals. Hazeldene Nursing Home DS0000021784.V261910.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 17. Full records of all complaints made were available within the home. The CSCI as received no complaints about this home since the last inspection. The service users legal rights were protected. EVIDENCE: The manager said that eight-service user had their legal rights protected by individual solicitors or the Court of Protection. She also said that if any other service users requested access to advocacy services then she would facilitate the service for them, if requested. The homes accounts had been recently audited. Hazeldene Nursing Home DS0000021784.V261910.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,24 and 26. The location and layout of the home is suitable for its stated purpose and the service users said they felt safe. Service users bedrooms in the main met individual’s needs in a comfortable and homely way, but some bedrooms did not have a lockable facility. The home was generally clean, but some hygiene procedures need improving. Some areas of the building were in need of redecoration and some easy furniture needs replacing. EVIDENCE: Relatives and service users said that the home was always clean; this they said made them feel safe because the home was well looked after by the staff group. Some areas had damaged decoration and damaged furniture. The bedroom doors were fitted with suitable door locks but lockable facilities were not provided in all the bedrooms. The service users spoken to were happy with most aspects of their room. Hazeldene Nursing Home DS0000021784.V261910.R01.S.doc Version 5.0 Page 16 Lounges and dining rooms were homely and attractive but some of the furniture was damaged. Making parts of the home look shabby. Service users could choose to meet with their visitors in these rooms or in the privacy of their own bedroom. The appropriate seating had been provided in the garden for those service users wishing to sit outdoors whenever the weather permitted. Each floor had a number of toilets and bathrooms provided as required. Toilets were easily accessible as they were close to lounge and dining areas. Several of the bins used to house soiled waste were not fitted with lids. The string light cords were badly stained in some bathrooms and toilets. Hazeldene Nursing Home DS0000021784.V261910.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30. The staff said that in the main, staffing levels were enough to meet the needs of the service users. Service users spoken to said that staff were kind and helpful. The home had a training and development plan and all staff had completed a range of training relevant to their role. The recruitment procedures were sufficiently robust enough to protect the welfare of service users. EVIDENCE: The staff said that in the main, staffing levels were enough to meet the needs of the service users. Service users said that staff were always there to help them and they felt safe. Relatives felt there was always enough staff on duty, and said they observed staff being very attentive to service users. Three staff files were checked; the files did demonstrate a thorough recruitment process had been followed as required by the regulations. CRB checks had been done and two references obtained, no gaps were noted in staff’s employment history. The homes induction programme met required standard and staff spoken to said it covered such things as safe working practices, the organisation and workers role and the needs of the service user group. This ensures that the service users are in safe hands at all times. Hazeldene Nursing Home DS0000021784.V261910.R01.S.doc Version 5.0 Page 18 Training needs of care staff were identified via supervision and appraisal sessions. Staff had completed training on NVQ in care and this had ensured that 40 of the staff team were qualified to level 2. Staff spoken to confirmed they receive much more than three days paid training, this demonstrates the provider’s commitment to investing in the staff. Hazeldene Nursing Home DS0000021784.V261910.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32 33,34 35 and 38. The service users and staff said the manager was approachable and very professional. The manger had a nursing and management qualification. A representative from the organisation visits the home on a regular basis a report is not being submitted following his visits. An auditor had recently undertaken an audit of the homes financial procedures. Records were in the main up to date and well organised. More Care needs to be taken with the storage of hazardous substances Hazeldene Nursing Home DS0000021784.V261910.R01.S.doc Version 5.0 Page 20 EVIDENCE: The manager had a job description that clearly defined her roles and responsibilities and staff were aware of her role. Staff and service users said that she was committed to ensuring that the home maintains and develops high standards of care, she had completed regular internal audits on all aspects of the service provided by the home. Service users and relatives confirmed that they could see the manager when they wished and they said that she was very approachable and supportive. The staff described her as `very good`. Records were securely stored as required and those checked were accurate and up to date and in good order. The responsible individual was visiting the home on a regular basis and talking to staff and service users, a report was not being written following the visit. Staff spoken to had an understanding of the home’s fire procedures; they had received training on moving and handling, food safety and infection control. The manager stated that there was a programme for the regular servicing and maintenance of all appliances. No fire exits were blocked and all fire doors were closing on their rebates. A health and safety check had recently been undertaken by an outside contractor and the manager said recommendations made by them had been actioned. The administrator handles money on behalf of some service users, account sheets were kept and an auditor had checked the system recently. Hazardous substances were noted to be insecurely stored in a kitchenette. This does not ensure a safe environment for service users. Hazeldene Nursing Home DS0000021784.V261910.R01.S.doc Version 5.0 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 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 2 10 X 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 4 18 X 1 X X X X 2 X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 3 4 X X 2 Hazeldene Nursing Home DS0000021784.V261910.R01.S.doc Version 5.0 Page 22 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 2 3 4 5 6 7 8 Standard OP9 OP19 OP24 OP19 OP26 OP26 OP30 OP33 Regulation 13 23 16 23 12 23 18 26 Requirement Medication for external use must be kept in a secure place at all times. Those areas with stained decoration must be redecorated A lockable facility must be provided in each bedroom. The damaged furniture must be replaced. The string light cords must be replaced. Bins used to house soiled waste must be fitted with a lid. At least 50 of the staff must be trained to NVQ level 2 A report must be produced following the responsible individuals monthly visit to the home. A copy must be sent to local office of the CSCI. Hazardous substances, must be kept in a secure place at all times. Timescale for action 03/11/05 01/05/06 01/05/06 01/05/06 01/02/06 01/12/05 01/05/06 01/02/06 9 OP38 12 03/11/05 Hazeldene Nursing Home DS0000021784.V261910.R01.S.doc Version 5.0 Page 23 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 Hazeldene Nursing Home DS0000021784.V261910.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 Nursing Home DS0000021784.V261910.R01.S.doc Version 5.0 Page 25 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!