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Inspection on 06/09/05 for Hazeldene Nursing Home

Also see our care home review for Hazeldene Nursing Home for more information

This inspection was carried out on 6th September 2005.

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 but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home is homely, friendly and welcoming. Service users said they liked living at the home where they were well cared for by staff. All areas of the home were clean. Each service user had a plan of care that detailed their needs and what the staff had to do to provide the care needed. Health care needs were met and service users received visits from health care professionals e.g. chiropodist, dentist, GP etc. Meals were thought to be good in the main. There was a complaints procedure that the staff and service users knew about. The person responsible for the home now has regular contact with the staff and service users and submits monthly report about the home, which included comments from the service users and staff.

What has improved since the last inspection?

Several rooms have been re-decorated, all parts of the home were clean and tidy and some new furniture and equipment had been purchased. Improvements have been made with the administration and recording of medication. Meal times were better organised and staff were noted to interact well with the service users at 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.

What the care home could do better:

Some areas around the home still need redecorating, some easy chairs need cleaning and more care is needed with some health and safety practises. Other professionals should be approach to offer advice and support with those service users with behavioural problems. The service users name should be on their bedroom doors to assist them when they are looking for their own room. The CSCI must be notified of all notifications in accordance with Regulation 37 of The Care Homes Regulations.

CARE HOMES FOR OLDER PEOPLE Hazeldene Nursing Home 84 Poole Road Darnall Sheffield S9 4JQ Lead Inspector Janice Griffin Unannounced 6 September 2005 09:30 th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Hazeldene Nursing Home J55 S21784 Hazeldene V218778 060905 UI Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Hazeldene Nursing Home Address 84 Poole Road Darnall Sheffield S9 4JQ 0114 2425757 0114 2421312 Not known S & S Health Care Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Susan Horne N Care Home with Nursing 60 Category(ies) of DE(E) Dementia - over 65 (60) registration, with number of places Hazeldene Nursing Home J55 S21784 Hazeldene V218778 060905 UI Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 20th May 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 J55 S21784 Hazeldene V218778 060905 UI Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place from 9:30 am to 2:45 pm. As part of the inspection process two-service users, three relatives and four staff, including the manager, were spoken to. A number of records were examined and several areas of the building were inspected. The inspectors were pleased to note that throughout the inspection staff interacted positively and sensitively with each service user. The inspectors would like to thank service users, relatives, the manager and staff for their commitment to the inspection process. What the service does well: What has improved since the last inspection? Several rooms have been re-decorated, all parts of the home were clean and tidy and some new furniture and equipment had been purchased. Improvements have been made with the administration and recording of medication. Meal times were better organised and staff were noted to interact well with the service users at 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. Hazeldene Nursing Home J55 S21784 Hazeldene V218778 060905 UI Stage 4.doc Version 1.40 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 J55 S21784 Hazeldene V218778 060905 UI Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Hazeldene Nursing Home J55 S21784 Hazeldene V218778 060905 UI Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1and 2. The home had a detailed service user guide and statement of purpose that clearly provided service users and their relatives with the necessary information regarding the services and facilities provided by the home. Service users were able to have informal introductory visits to the home and at the time of their admission and had been provided with a contract containing the relevant information. EVIDENCE: The statement of purpose and service user guide contained all of the required information. Copies were available and the manager confirmed that they would be available in alternative formats should the service users request this. Both documents were explained and read out to service users on a regular basis. An up to date contract/statement of terms and conditions had been provided to service users and 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 J55 S21784 Hazeldene V218778 060905 UI Stage 4.doc Version 1.40 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9 and 10. Service users had their needs set out in an individual plan of care and in most case health care needs were fully met. Where appropriate service users were able to administer their own medication. 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. Staff were finding it difficult to cope with the behaviour of one service user. EVIDENCE: Relatives said they were consulted about service users care plans and they knew that the home kept records, which they were able to look at if they wished. Staff said that care plans were reviewed regularly in consultation with other staff, service users and relatives. Hazeldene Nursing Home J55 S21784 Hazeldene V218778 060905 UI Stage 4.doc Version 1.40 Page 10 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. It was noted that one service user was refusing help from carers with such things as assisting him with his personal care needs; he was also abusive at times. No help had been requested from other professionals. The staff need support and guidance from other professional carers to assist them when dealing with such problems. Hazeldene Nursing Home J55 S21784 Hazeldene V218778 060905 UI Stage 4.doc Version 1.40 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13,14 and 15. Service users were able to maintain contact with family and friends and representatives of the community if they wished. Service uses were helped to make choices and to have some control over their lives. The meals provided were balanced, to the liking of the service users and served in pleasing surroundings. EVIDENCE: Service users were consulted about how they spent there time, when to get up and go to bed and who to spend time with. 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. They were offered alternatives and encouraged to make choices and to be as independent as possible. Service users were offered three full meals a day and those spoken to said the food was “very good”, there was always plenty and snacks were provided inbetween meals. Lunch was observed the meal was unhurried and staff encouraged those service users who were reluctant to eat. Hazeldene Nursing Home J55 S21784 Hazeldene V218778 060905 UI Stage 4.doc Version 1.40 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18. The homes complaints procedure was clear, accessible and contained all the necessary information. Staff had a good understanding of the procedure and timescales involved. Relatives and service users were aware that they could complain. The complaints record was available within the home. The homes policies and procedures protected service users from abuse. EVIDENCE: The complaints procedure was available for service users, their relatives and staff. Relatives 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 confirmed that staff were always available and that they were encouraged to talk about anything that troubled them or caused them anxiety. The complaints record confirmed that one complaints had been made to the CSCI since the last inspection. Staff had received formal adult protection training. This helps to ensure that service users are protected from abuse Hazeldene Nursing Home J55 S21784 Hazeldene V218778 060905 UI Stage 4.doc Version 1.40 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,23,24,25 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 the service users name on the door and a lockable facility. The home was generally clean. Some areas of the building were in need of redecoration and some easy chairs need cleaning or 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. The bedroom doors were fitted with suitable door locks but lockable facilities were not provided in all the bedrooms and some bedroom doors did not have the service users name on. This can confuse the service users, as all the bedroom doors look the same. The service users spoken to were happy with most aspects of their room. Hazeldene Nursing Home J55 S21784 Hazeldene V218778 060905 UI Stage 4.doc Version 1.40 Page 14 Lounges and dining rooms were homely and attractive but some of the easy chairs were stained in parts. 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. Hazeldene Nursing Home J55 S21784 Hazeldene V218778 060905 UI Stage 4.doc Version 1.40 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29 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 not 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 not demonstrate a thorough recruitment process had been followed as required by the regulations. CRB checks had been done and two references obtained, but 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. 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 several members 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 J55 S21784 Hazeldene V218778 060905 UI Stage 4.doc Version 1.40 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,34,35,37 and 38. Records were in the main up to date and well organised. The homes policies and procedures met the required standards. It was noted that the CSCI had not been notified of notifications in accordance with the regulations. Comprehensive accounting systems were in place to safeguard service users finances although a correlation of those records with service users actual monies was unable to be carried out. A safe environment is not provided in all parts of the home. Hazeldene Nursing Home J55 S21784 Hazeldene V218778 060905 UI Stage 4.doc Version 1.40 Page 17 EVIDENCE: Records were securely stored as required and those checked were accurate and up to date and in good order. It was noted that the CSCI had not been notified of notifications in accordance with the Care Homes Regulations 2001. The responsible individual was now visiting the home on a regular basis and talking to staff and service users, a report was written following the visit. This allows the provider to ensure that the home is run in the best interest of the service users. 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. One fire door was not fully closing on its rebate and an upper floor window was opening too wide. Domestic staff were noted to be mopping floors and wet floor signs were not used. This is not safe for service users. Hazeldene Nursing Home J55 S21784 Hazeldene V218778 060905 UI Stage 4.doc Version 1.40 Page 18 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 3 x x 3 2 3 3 STAFFING Standard No Score 27 3 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 3 3 x 2 1 Hazeldene Nursing Home J55 S21784 Hazeldene V218778 060905 UI Stage 4.doc Version 1.40 Page 19 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. Standard 38 19 24 Regulation 23 23 16 Requirement All fire doors must fully close on their rebates. Those areas with stained decoration must be redecorated All bedrooms must have a lockable facility unless it is recorded in the service users care plan that they do not require one or cannot operate one. Gaps in staffs employment history must be explored. Professional help must be requested for those service users who have behaviour problems that the staff cannot cope with. Medication for external use and hazardous substances, must be kept in a secure place at all times. The stained easy chairs must be cleaned or replaced. Window restrainers must be fitted to all upper floor windows. All bedroom doors should contain the name of the service user that occupies the room. Wet floors signs must be used when floors are being mopped. The registered person must notify the local office of the CSCI J55 S21784 Hazeldene V218778 060905 UI Stage 4.doc Timescale for action Immediate 1/12/05 1/12/05 4. 5. 29 8 19 12 Immediate 1/11/05 6. 9 13 Immediate 7. 8. 9. 10. 11. 19 38 24 38 37 16 12 16 12 37 1/11/05 Immediate 1/11/05 Immediate Immediate Page 20 Hazeldene Nursing Home Version 1.40 of the occurrence of events detailed in Regulation 37. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 31 Good Practice Recommendations By 2005 the manager must have NVQ level4 in management. Hazeldene Nursing Home J55 S21784 Hazeldene V218778 060905 UI Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection 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 J55 S21784 Hazeldene V218778 060905 UI Stage 4.doc Version 1.40 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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