Inspection on 08/05/06 for Hazeldene Nursing Home

This inspection was carried out on 8th May 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 but made no statutory requirements on the home.

Other inspections for this house

Hazeldene Nursing Home 25/04/07

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 8th May 2006 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.V291480.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 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.V291480.R01.S.doc Version 5.1 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) None 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.V291480.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th February 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: £435 for nursing and £341 for residential care. This information was provided on the 8th May 2006. The home charges extra for chiropody, toiletries, clothing, telephone, holidays and hairdressing. Hazeldene Nursing Home DS0000021784.V291480.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 key inspection carried out by Janice Griffin and Shirley Samuels, regulation inspectors. This inspection took place between the hours of 7.00 am and 2:40 pm. Susan Horne, the registered manager was present during the inspection. Most of the service users were seen during the inspection. None of the service users were able to contribute to the inspection process so the inspectors spent time observing the direct care offered to the service users. Observations confirmed that service users were extremely comfortable and at ease in the company of the managers and staff. Two relatives, eight staff and the managers on duty were spoken to. One relative described the service as in the main very good but another had some concerns about her fathers care. Her concerns were brought to the attention of the manager who met with the relative to discuss ways of improving the care provided to her father, the relative said she was happy with the arrangements made. A number of records were examined which included, the managers preinspection questionnaire, medication records, three service users care plans, three weeks menus and three weeks staff rotas. Records relating to staff recruitment, service users finances, staff training and the homes quality assurance systems were also checked. Several areas of the building were also inspected. One complaint has been received at the home since the last inspection the complaint was about the attitude of two members of staff. The complaint was investigated by the manager and was not upheld. Requirements in the report have been made with regard to relative’s involvement with care planning and reviews. Medication recording charts must be signed to show that medication has been given or not and the service users must have a supply of their prescribed medication in stock. Some areas needing to be redecorated and a lockable facility must be provided in each bedroom. Service users must be offered a choice of food at meal times and footplates must be in situ on wheelchairs when transporting service users around the home. Requirements have also been made about the homes recruitment procedures, which must also be improved. Feedback on the inspection was given to the managers before the inspectors left the home. What the service does well: The inspectors observed that service users were well dressed in clean clothes and had received a good standard of personal care. Hazeldene Nursing Home DS0000021784.V291480.R01.S.doc Version 5.1 Page 6 Service users had visited the home for trial periods and full detailed needs assessments have been completed prior to their admission. Service users were only admitted once it had been determined that the home could meet their needs. Service users were encouraged and supported to maintain positive relationships with their families and friends. Service users were encouraged to eat a healthy diet. Staff handovers were taking place on a daily basis; these meetings enabled the staff to discuss the current health needs of service users, to ensure that a consistent level of care could be offered. All service users attended a variety of social and leisure activities and these were based very much on the personal preferences of each individual. The home caters well for service users with disabilities and those with special dietary needs. Feedback was being sought on a regular basis from relatives, and other professionals involved with each individual. One relative spoke positively about the staff team and the care that their relative received. He commented that all the staff was “smashing”. The service users finances were well managed. 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. Hazeldene Nursing Home DS0000021784.V291480.R01.S.doc Version 5.1 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.V291480.R01.S.doc Version 5.1 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 and 6. Quality in this outcome area is: good. This judgement has been made using available written evidence, discussion with two relatives and a visit to the home. No service user moves into the home without having his or her needs assessed which ensures that their care needs will be met. Service users were able to have informal introductory visits to the home at the time of their admission. The relatives confirmed that this helped the service users to get to know everyone at the home, which made them feel less anxious. This home does not provide intermediate care services. EVIDENCE: Detailed full needs assessments have been completed by the referring social worker for all service users admitted to the home. Families had been involved in the assessment process as appropriate. Hazeldene Nursing Home DS0000021784.V291480.R01.S.doc Version 5.1 Page 9 The manager confirmed that service users were only admitted to the home once they were sure that they could meet their needs. Relatives spoken to said at the time of the service users admission they were able to have informal introductory visits to the home and they had been provided with a contract containing the relevant information. Records checked confirmed that service users families had been involved in decisions regarding the arrangements. An up to date contract/statement of terms and conditions had been provided to service users. These clearly detailed the fees, including any extra charges, and the services and facilities provided by the home Hazeldene Nursing Home DS0000021784.V291480.R01.S.doc Version 5.1 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): 7,8,9 and10. Quality in this outcome area is: adequate. This judgement has been made using available written evidence and observations made by the inspectors at the visit to the home. Observations made by the inspectors confirmed that the staff promoted the service users privacy and dignity. The information in two care plans was inadequate to ensure that the service users health and social care needs could be met. This does not protect the well being of service users. One other care plan checked was of a good standard and the service users health; social and personal care needs were well documented. There was no evidence to show that relatives were involved in the care planning or reviewing process. This does not allow the relatives to have a say in how the service users needs are being met. Some medication practices could cause a risk to the service users health and welfare. Hazeldene Nursing Home DS0000021784.V291480.R01.S.doc Version 5.1 Page 11 EVIDENCE: Three service users plans of care were checked. Each set out individual most of the service users needs and the action required and taken by staff to ensure those needs were met. Discussion with staff identified that a range of health professionals visited the home to assist in maintaining health care needs. Two-service users care plans showed that their nutritional needs had not been checked for several weeks, these care plans also, did not give any information about the service users social/leisure needs. Relatives were not being involved in the care planning or review process. Staff were observed to be assisting service users in a positive and friendly manner, doors were closed where staff were assisting with personal care. A range of aids to assist service users with mobility problems were provided; these included lifting hoists, assisted baths, walking frames and wheelchairs. Records were kept of medication received, and disposed of and the medication administration system was managed reasonably well. One medication recording charts had not been signed on one occasion to show whether medication had been given or not. One service user had run out of her prescribed medication. Medication was securely stored. A pharmacist had checked the home’s medication systems in February 2006 and no issues of concern were reported. Hazeldene Nursing Home DS0000021784.V291480.R01.S.doc Version 5.1 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): 12,13,14 and 15. Quality in this outcome area is: good. This judgement has been made using available written evidence, discussions with two relatives and six staff members and a visit to the home Service users had access to a range of leisure activities based on their individual choices and preferences. Service users were supported with maintaining and developing contact with their family and friends, and relatives said that they were always welcome at the home. Which creates a home that people want to visit. A good choice of food was not offered to all service users at breakfast time. This does not promote the rights and choices of service users. EVIDENCE: Relatives and staff confirmed that the activities co-ordinator ensured that service users were regularly supported with their leisure and social needs. A programme of the daily leisure activities was displayed on the notice board. Staff confirmed that service users had regular contact with representatives from the local churches and that they were able to visit them at the home if they wished. Throughout the day friends and family were seen visiting freely and being offered hospitality. Hazeldene Nursing Home DS0000021784.V291480.R01.S.doc Version 5.1 Page 13 The inspectors observed breakfast and lunch, the meals served looked appetising and plenty of choice of food was available. Staff in one dining room however did not offer service users a choice of food and drink at breakfast time. Five service users were receiving special diets. Special cutlery and crockery was provided for those service users who had difficulty using knives and forks. Hazeldene Nursing Home DS0000021784.V291480.R01.S.doc Version 5.1 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): 16 and 18. Quality in this outcome area is: good. This judgement has been made after discussion with two relatives, six staff members and using available written evidence including a visit to the home. The homes complaints procedure was clear, accessible and contained the necessary information. This is good management practice. Service users were protected from abuse by the awareness of staff through training and the homes procedures. EVIDENCE: The complaints procedure was available for service users, their relatives and staff. The manager confirmed that this would be available in alternative formats and languages should this be requested. All relatives and staff 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. The complaints record confirmed that one complaint has been made at the home since the last inspection. The complaint was about the attitude of two staff members. This complaint had been investigated by the manager but was not upheld. Staff had received formal adult protection training this included dealing with physical, emotional and sexual abuse. The manager was aware of the Sheffield City Councils adult abuse procedures. One allegations of abuse have been made at this home since the last inspection this allegation had been investigated by the manager but was not upheld. Staff had been made aware of the action to take in dealing with third party information. Hazeldene Nursing Home DS0000021784.V291480.R01.S.doc Version 5.1 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. Quality in this outcome area is: adequate. This judgement has been made after and using available evidence, including a visit to the home. The environment within the home was clean providing a comfortable environment for service users. Some decoration was damaged making the home look shabby in parts. The Environmental Health Officer had recently visited the home and made a requirement, the requirement has not yet been actioned. This could impose on the service users health and wellbeing. Hazeldene Nursing Home DS0000021784.V291480.R01.S.doc Version 5.1 Page 16 EVIDENCE: Some parts of the home had been redecorated and the carpets and furniture replaced, but some areas still had damaged decoration. The bedroom doors were fitted with suitable door locks and lockable facilities were provided in most bedrooms but not all. Service users could smoke in a designated smoking area. 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. Assisted baths and showers were provided for those service users with mobility problems. Toilets were easily accessible as they were close to lounge and dining areas. All the toilets have been adapted for service users with physical disabilities. Staff confirmed that they were provided with protective clothing if they needed it and that all the equipment was in good working order and that it had been serviced as required. The Environmental Health Officer had recently visited the home and made a requirement about the kitchen needed decorating, the requirement has not yet been actioned. Hazeldene Nursing Home DS0000021784.V291480.R01.S.doc Version 5.1 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. Quality in this outcome area is: adequate. This judgement has been made after discussion with five staff and using available written evidence including a visit to the home. Care staff had a range of skills and experience, which effectively supported the service users. This will ultimately benefit the health and welfare of the service users. The recruitment information obtained for new staff was not adequate to protect the welfare of service users who lived at the home. At least 50 of staff have undertook NVQ training at level 2 or 3, and all staff had completed a range of training relevant to their role. This shows the providers commitment to staff development. Hazeldene Nursing Home DS0000021784.V291480.R01.S.doc Version 5.1 Page 18 EVIDENCE: The staff and relatives said that there was always enough staff on duty. Three staff files were checked; criminal record checks had been done for all three staff, but one record did not state whether the check was clear or not. Two references had been obtained but gaps were noted in two staff’s employment history and one file did not contain any proof of identity. 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 five staff and the manager confirmed that all staff had completed detailed induction training. Staff were observed to be approachable and sensitive to the needs of service users and were able to communicate effectively with each person. Staff had completed training on NVQ in care and this had ensured that more than 50 of the staff team were qualified to level 2/3. Staff were being formally supervised at the frequency specified in the Regulations and Standards to fully ensure individual staff development and the monitoring of care practices Hazeldene Nursing Home DS0000021784.V291480.R01.S.doc Version 5.1 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): 31,33,35 and 38. Quality in this outcome area is: adequate. This judgement has been made after discussion with the manager and five staff and using available written evidence including a visit to the home. Records were in the main up to date and well ordered to ensure the best interests of service users. The homes policies and procedures met the required standards. A safe environment was not provided in all parts of the home. This could affect the health and welfare of the service users. Hazeldene Nursing Home DS0000021784.V291480.R01.S.doc Version 5.1 Page 20 EVIDENCE: The manager had a job description that clearly defined her roles and responsibilities and staff were aware of her role. She said she was committed to ensuring that the home provides a high standards of care, she has started to complete regular internal audits on all aspects of the service provided by the home. There was a quality assurance system, which sought the views of relatives. The responsible individual visits the home on a regular basis a report is written following the visits. A copy of the responsible individuals monthly report is sent to the local office of the CSCI. Two staff members were noted to be pushing service users around the home in wheelchairs with no footplates in situ. The Environmental Health Officer visited the home in February 2006 he required that the kitchen be redecorated. This requirement has not been actioned. No fire exits were blocked and hazardous substances were securely stored. The administrator handles money on behalf of some service users, account sheets were kept, receipts were available for all transactions and all transactions were witnessed by a second individual. Hazeldene Nursing Home DS0000021784.V291480.R01.S.doc Version 5.1 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 N/A DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X 2 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 3 2 Hazeldene Nursing Home DS0000021784.V291480.R01.S.doc Version 5.1 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. Standard OP7 OP8 OP9 OP9 Regulation 15 15 13 13 Requirement Relatives must be asked to be part of the care planning and review process. Care plans must include details of the service users nutritional, leisure and social needs. Service users must at all times have a supply of their prescribed medication in stock. Medication charts must always be signed to show whether medication has been given or not. Those areas with stained decoration must be redecorated. This requirement has been outstanding since September 2004. A lockable facility must be provided in each bedroom. This requirement has been outstanding since September 2004. All service users must be offered a choice of food at all meals. DS0000021784.V291480.R01.S.doc Timescale for action 01/07/06 01/07/06 08/05/06 08/05/06 5. OP19 23 08/07/06 6. OP24 16 01/08/06 7. OP15 16 08/05/06 Hazeldene Nursing Home Version 5.1 Page 23 This requirement has been outstanding since February 2006. 8. OP29 19 A thorough recruitment system must be adhered to as required by the Standards and Regulations. The requirement made by the Environmental Health officer must be actioned. Footplates must be in situ on wheelchair when staff are wheeling service users around. 01/07/06 9 10. OP38 OP38 23 12 01/08/06 08/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Hazeldene Nursing Home DS0000021784.V291480.R01.S.doc Version 5.1 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.V291480.R01.S.doc Version 5.1 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. 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