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Inspection on 13/06/06 for Hazelgrove Care Home

Also see our care home review for Hazelgrove Care Home for more information

This inspection was carried out on 13th June 2006.

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.

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

A kind and caring ethos was prevalent throughout the home and on observation staff were observed to have meaningful interaction with service users. Service users spoken with spoke highly of the staff and care received. Relatives spoken with stated they were made welcome into the home and it was evident that a good rapport was maintained. Staff spoken with were able to discuss the care values and principles and service users needs. Staff are working towards ensuring training is at a high standard and 80% of staff have now obtained the National Vocational Qualification.

What has improved since the last inspection?

Risk assessments have made improvement since the previous inspection ensuring service users are protected. Care plans have made a significant improvement working towards ensuring appropriate plans of care are in place thus ensuring service users needs are met. Further attention has taken place with regards to ensuring agency staff complete necessary documentation and the agency used has been changed, thus working towards ensuring service users are protected. The recruitment polices have improved ensuring service users are further protected. Procedures with regards to the handling of service users personal allowances have made an improvement working towards ensuring service users finances are protected. Several service users rooms and bathrooms have been redecorated ensuring a pleasant and comfortable environment for service users.

What the care home could do better:

Whilst it is acknowledged that care plans have made a vast improvement it is required that attention is given with regards to assistance and facilitation service users require in order to ensure needs are fully met. To ensure the safe administration of medication it is required that staff continue to work towards the remaining issues highlighted during the recent pharmacy inspection. To ensure the issues with regards to agency catering staff is fully resolved the administrator is required to liaise with the agency to address this, thus ensuring service users are fully protected. As noted records in respect of service users personal allowances have made improvement it is now required that on completing the monthly reconciliation that evidence is available to demonstrate that service users accounts and monies correspond.It is required that further attention is given to the remaining staff personal files to ensure all documentation as listed in schedule 2 is available for inspection, to ensure service users are fully protected. To ensure service users are fully protected it is required that risk assessments are in place with regards to the water temperatures. An up to date copy of the homes mains electrical test is required to be forwarded to the Commission for Social Care Inspection to demonstrate this has been completed thus ensuring the health and safety of service users and relevant others.

CARE HOMES FOR OLDER PEOPLE Hazelgrove Care Home 1a Farleys Lane Hucknall Nottingham NG15 6DY Lead Inspector Karmon Hawley Unannounced Inspection 13th June 2006 10:00 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 Hazelgrove Care Home DS0000026444.V288117.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. Hazelgrove Care Home DS0000026444.V288117.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Hazelgrove Care Home Address 1a Farleys Lane Hucknall Nottingham NG15 6DY 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) 0115 9680706 0115 9680706 Mr Gerald Hudson Care Home 40 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (40), of places Physical disability (2), Terminally ill (2) Hazelgrove Care Home DS0000026444.V288117.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Within the total number of beds 2 beds may be used for the category PD, 2 beds may be used for the category TI and 10 beds for DE/E Date of last inspection Brief Description of the Service: Hazelgrove is a purpose built single storey care home situated in a residential area of Hucknall, for forty people over the age of 65years. There are thirty-six single and two double rooms; none of which have ensuite facilities. It is situated near to a doctor’s surgery, within half a mile of shops, a public house, cinema, library, tourist sights and other local amenities in the town centre of Hucknall. Hucknall is supported by good transport links into the city of Nottingham. An enclosed garden provides a safe outside environment for the service users in good weather. Communal care parking is also available. The home provides both nursing and residential care. It can also accommodate up to two people with physical disability, ten with dementia care needs and two for palliative care. The current weekly fees are as follows: nursing care needs £443, dementia care needs £339 and residential care £390. The required information is made available at the point of enquiry. Hazelgrove Care Home DS0000026444.V288117.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Prior to the site visit an analysis of the performance of the home over the previous year took place in line with the key national minimum standards. The evidence gained was assessed and thus the site visit planned in accordance with further evidence required to demonstrate compliance with the national minimum standards. One inspector undertook the site visit over course of four and a half hours. The main method of gaining evidence during the site visit was case tracking, this is a method of sampling the records of four randomly selected service users to ascertain if the needs of service users are appropriately assessed and identified needs are being catered for by the home to maintain optimum health and wellbeing of the service user. Seven service users and two relatives were spoken with so as to give the inspector an insight into the conditions and standards within the home. Those spoken with were happy with the staff, care received and the standards within the home. The acting manager and the care and development manager assisted in the site visit and two members of staff were spoken with. Staff were able to demonstrate an understanding of service users needs and the core values and principles in relation to their job roles. What the service does well: What has improved since the last inspection? Hazelgrove Care Home DS0000026444.V288117.R01.S.doc Version 5.1 Page 6 Risk assessments have made improvement since the previous inspection ensuring service users are protected. Care plans have made a significant improvement working towards ensuring appropriate plans of care are in place thus ensuring service users needs are met. Further attention has taken place with regards to ensuring agency staff complete necessary documentation and the agency used has been changed, thus working towards ensuring service users are protected. The recruitment polices have improved ensuring service users are further protected. Procedures with regards to the handling of service users personal allowances have made an improvement working towards ensuring service users finances are protected. Several service users rooms and bathrooms have been redecorated ensuring a pleasant and comfortable environment for service users. What they could do better: Whilst it is acknowledged that care plans have made a vast improvement it is required that attention is given with regards to assistance and facilitation service users require in order to ensure needs are fully met. To ensure the safe administration of medication it is required that staff continue to work towards the remaining issues highlighted during the recent pharmacy inspection. To ensure the issues with regards to agency catering staff is fully resolved the administrator is required to liaise with the agency to address this, thus ensuring service users are fully protected. As noted records in respect of service users personal allowances have made improvement it is now required that on completing the monthly reconciliation that evidence is available to demonstrate that service users accounts and monies correspond. Hazelgrove Care Home DS0000026444.V288117.R01.S.doc Version 5.1 Page 7 It is required that further attention is given to the remaining staff personal files to ensure all documentation as listed in schedule 2 is available for inspection, to ensure service users are fully protected. To ensure service users are fully protected it is required that risk assessments are in place with regards to the water temperatures. An up to date copy of the homes mains electrical test is required to be forwarded to the Commission for Social Care Inspection to demonstrate this has been completed thus ensuring the health and safety of service users and relevant others. 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. Hazelgrove Care Home DS0000026444.V288117.R01.S.doc Version 5.1 Page 8 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 Hazelgrove Care Home DS0000026444.V288117.R01.S.doc Version 5.1 Page 9 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 The quality rating for this outcome area is good this judgement was made using evidence available including a visit to the service. Service users may be assured their needs will be assessed and met prior to moving into the home. EVIDENCE: Relatives and prospective service users may visit the home prior to admission. The acting manager and the administrator visit prospective service users in the community to carry out pre admission assessments. The assessment covers the requirements of this standard. Hazelgrove Care Home DS0000026444.V288117.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): 7,8,9,10 The quality rating for this outcome area is adequate this judgement was made using evidence available including a visit to the service. Care plans continue to develop working towards ensuring service users needs are set out in a plan of care. Service users health care needs are fully met. Whilst service users are protected by the homes medication policies and procedures, minor improvements are required to ensure service users are fully protected. Service users feel they are treated with respect and their right to privacy is upheld. Hazelgrove Care Home DS0000026444.V288117.R01.S.doc Version 5.1 Page 11 EVIDENCE: The majority of service users care plans are now transferred to the new documentation. The new package is more in depth and aimed towards improving care. The package ensures care plans are of a holistic approach and reflect likes, dislikes and preferences of service users. There was evidence to demonstrate that some areas are still to be completed and developed, the acting manager is intending to hold further workshops to implement this. Service users undergo various assessments such as the activities of daily living; nutrition, pressure area, and risk, information gained underpins the plan of care. Care plans demonstrated individuality and service users likes, dislikes and preferences were fully considered. All relevant information was available with regards to complex needs, however within two care plans case tracked there was no action to be taken to ensure service users needs are fully met. Within two service users care plans not all assessments had been completed; the acting manager stated this was due to the transfer of documentation. Appropriate risk assessments were in place. Daily records were maintained were in depth and covered significant events. Service users spoken with stated that their needs were met and they were treated as individuals and staff listened to their needs. Staff spoken with were able to discuss service users needs. There was evidence of the multidisciplinary team and specialist services being liaised with and accessed, there are also link staff within the home to enhance these services. Specialist equipment and aids were available. One service user spoken with stated that staff contacted the doctor when needed. A new medication policy has been implemented. The supplying pharmacy visits the home periodically to carry out inspections on the medication procedures, this had been done the previous day of the inspection and a several recommendations had been made. On examination there was evidence to demonstrate that some areas that had been recommended had been actioned, however there were further areas to be actioned, such as ensuring prescriptions correspond with the administration sheet and ensuring hand written entries have two signatures. If private visits are required the service user may use their own room the dining room or the little lounge. All service users spoken with stated that staff were respectful at all times, one service user substantiated that staff knock on doors prior to entering their rooms. There is a pay phone and a hands free telephone available for service users use. Mail is given unopened unless service users ask for it to be opened. Private and confidential correspondence is given to relatives if service users are unable to receive this. Hazelgrove Care Home DS0000026444.V288117.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): 12,13,14,15 The quality rating for this outcome area is good this judgement was made using evidence available including a visit to the service. Service users are enabled to find the lifestyle in the home satisfies their expectations and preferences and satisfies their needs. Service users are enabled to maintain contact with relevant others. Service users are helped to exercise choice and control over their lives and equality and diversity of service users is recognised within the ethos of the home. Service users receive a wholesome and appealing diet, measures have been taken with regards to ensuring the agency catering staff complete necessary documentation, however this needs additional attention to ensure the agency staff fully comply. Hazelgrove Care Home DS0000026444.V288117.R01.S.doc Version 5.1 Page 13 EVIDENCE: The staff spoken with stated that the routine within the home is flexible and service users may choose how they spend the day. Service users spoken with substantiated this. An activities coordinator is employed within the home and carries out activities on an individual and group basis. There are plans to develop this facility further to assess all service users needs and plan activities accordingly and to keep personal records of activities attended. A health promotion board and a plaudits board has been introduced into the home to offer further information for service users and relatives. As well as the in house entertainment outside facilitators also visit the home, service users spoken with substantiated this and two stated that although activities are available they choose not to join in whereas two others spoken with stated they enjoyed the activities on offer. There are two visiting church members who carry out church service on an individual and group basis and service users may visit the church in the community should they wish. Two service users spoken with stated that they often go out with their families. There are no restrictions imposed upon visiting and service users spoken with substantiated this and stated that their visitors were always made welcome. The two visitors spoken with also stated that a good rapport with staff was maintained and they were made welcome into the home at any time. Staff were observed to interact in a meaningful manner with both service users and visitors. There is a satisfactory policy in place with regards to visitors and the safety and security on entering and leaving the home. The visiting policy is discussed prior to service users entering the home. All consultations are carried out in private in service users own rooms or the medical room if appropriate. One service user deals with their own personal finances whereas all others at present are assisted by relevant others. Service users are enabled to hold money on the premises in the homes safe should they wish. Advocates are utilised as necessary and the acting manger is looking towards utilising advocates when service users are sent the new quality assurance questionnaires. Service users are encouraged and facilitated to bring in personal possessions. One service user spoken with stated that their room was very comfortable and personalised. Hazelgrove Care Home DS0000026444.V288117.R01.S.doc Version 5.1 Page 14 Meals are available throughout the day and supper on request. The choice on offer is at an excellent standard. Service users spoken with substantiated that there is a lot of choice and there is plenty of food. Kitchen records observed demonstrated as normal practice the homes kitchen staff continue to complete required documentation. Action has been taken with regards to the agency staff covering the home and the administrator has been overseeing this, there has been a change in agency catering staff to try to resolve the problem, however further attention is still required to ensure relevant documentation is completed. The dining chairs and table are still plastic garden furniture, however there are plans to redecorate and refurbish this area. The environmental health officer has recently visited the home recommendations set have been actioned. Hazelgrove Care Home DS0000026444.V288117.R01.S.doc Version 5.1 Page 15 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): 16,18 The quality rating for this outcome area is good this judgement was made using evidence available including a visit to the service. Service users and relevant others may be confident that their complaints will be listened to, taken seriously and acted upon. Service users are protected from abuse. EVIDENCE: An appropriate complaints policy and procedure is in place. Two complaints have been received since the previous inspection; there was evidence to demonstrate that these have been dealt with appropriately. Staff spoken with were able to discuss how they would respond should a complaint be received. Service users and relatives spoken with expressed they were happy with the service received and had no complaints. A new policy in regards to adult protection has been introduced, there was evidence available to demonstrate that staff had read this policy and signed to confirm this. Staff spoken with were able to discuss the relevant issues of adult protection and all staff have undertaken training in this area. All staff employed have current criminal record bureau checks in place. Hazelgrove Care Home DS0000026444.V288117.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 The quality rating for this outcome area is good this judgement was made using evidence available including a visit to the service. Service users live in a safe well-maintained environment; however further attention is required to the environmental issues highlighted in standard 38 to ensure service users are fully protected. The home is clean, pleasant and hygienic. Hazelgrove Care Home DS0000026444.V288117.R01.S.doc Version 5.1 Page 17 EVIDENCE: A maintenance man is employed and there was evidence to demonstrate that ongoing maintenance takes place. The acting manager stated that discussion with regards to the dining room furniture is ongoing and it is anticipated that these will be replaced once the room has been decorated. Service users have been involved in the choosing of the wallpaper for the dining room. A number of bathrooms and service users rooms have been redecorated since the previous inspection. The home on the day of the day of inspection was clean, pleasant and hygienic. There are sufficient hand wash facilities throughout the building and laundry facilities in place to meet the required standards. Hazelgrove Care Home DS0000026444.V288117.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 The quality rating for this outcome area is good this judgement was made using evidence available including a visit to the service. The numbers and skill mix of staff meets service users needs. Service users are in safe hands at all times. Service users are supported and protected by the homes recruitment policy and practices, however further attention is now required to ensure all relevant documentation is in place. Staff are trained and competent to do their jobs. EVIDENCE: The duty rota observed demonstrated that sufficient staff are employed to meet the needs of service users. Skill mix is taken into consideration when planning the duty rota. Staff spoken with stated that on occasion they experienced times when they were short of staff due to sickness and when unable to get agency staff cover for the kitchen. The acting manager and care and development manger are aware of these issues and looking towards resolving them. Both stated that standards of care are not reduced during these periods and service users needs are still fully met. Service users and visitors spoken with spoke very highly of staff and there were no concerns expressed with regards to staff availability. Hazelgrove Care Home DS0000026444.V288117.R01.S.doc Version 5.1 Page 19 A new in depth induction programme has been introduced which links with the National Minimum Standards. There was evidence available to demonstrate that this has been implemented. 80 of staff have attained the National Vocational Qualification level two, three are working towards the qualification and the remainder of staff are due to commence shortly. 3 members of staff have attained the National Vocational Qualification level three. Four staff files were observed, three did not have two references available, however these were longer term members of staff and one did not have any form of identification in place. All staff employed have satisfactory criminal record bureau checks in place. Each member of staff have individual training files. The acting manager is currently analysing all training and researching training providers to ensure staff are trained in all mandatory areas. Currently staff are making good progress towards this. Further training in addition to mandatory training is also being considered. On observing staff working practices, there were concerns with regards to manual handling techniques, these were discussed with the acting manager and care and development manager who will look into these issues further. Hazelgrove Care Home DS0000026444.V288117.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 The quality rating for this outcome area is adequate this judgement was made using evidence available including a visit to the service. The home is run and managed by a person of good character who is able to discharge her responsibilities. The home is working towards ensuring the home is run in the best interests of service users. Service users finances are safeguarded, however a minor improvement is required to demonstrate accounts are fully audited. The health, safety and welfare of service users and staff are promoted; however further input is required with regards to risk assessments in respect to the water temperatures. The mains electrical certificate is out of date the new certificate is to be forwarded to the Commission for Social Care Inspection to demonstrate this has been undertaken. Hazelgrove Care Home DS0000026444.V288117.R01.S.doc Version 5.1 Page 21 EVIDENCE: The homes current registered manager is still in employment at the home, a new acting manger is currently undergoing induction to take over this role. Once this has been completed it is her intention to apply to become the registered manager. The acting manager has previous experience in managing a home and is in the process of registering for an in depth course on dementia care needs and the registered managers award. She ensures she remains up to date by attending various study days and courses. She is currently in the process of completing an in depth induction and stated that she feel supported in her job role. Staff and service users spoken with spoken highly of the acting manager and the way in which the home is run. A quality assurance group has been set up where they look at all quality issues. Regulation 26 forms are forwarded to the Commission for Social Care Inspection as required. Health care professionals completed a quality assurance survey last year. A questionnaire for service users has now been devised and it is intended that this will be given out shortly. In addition to a an annual questionnaire there will also be smaller questionnaire specifically aimed at services of the home. There are regular service users, relatives and staff meetings where quality issues are discussed. A health and safety group has also been set up to address all health and safety issues. A cleaning and disinfection of water services policy is in the process of being implemented. All water tanks on one side of the building have been cleaned and there are plans to complete the remaining. Water temperatures remain unchanged and are still delivered at between 58 and 60oC, there was no risk assessments in place with this regards. The care and development manager stated she had requested that this was done in individual care plans, however had not been completed as yet. All servicing and maintenance certificate were in place wit the exception of the mains electrical testing, which was out of date. The acting manager stated that attempts had been made to address this, however the service provider was yet to contact the home. Once this has been completed a copy of the certificate will be forwarded to the Commission for Social Care Inspection. Hazelgrove Care Home DS0000026444.V288117.R01.S.doc Version 5.1 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 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X 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 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 X X 2 Hazelgrove Care Home DS0000026444.V288117.R01.S.doc Version 5.1 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 OP7 Regulation 15 Requirement The registered person is required to ensure care plans address how service users will be assisted and facilitated to ensure needs are fully met. The responsible individual is required to ensure the safe, recording, handling and administration of medicines. The registered person is required to ensure the safe handling, storage, preparation and serving of food. The catering company is to be liaised with to address outstanding issues. All staff employed are required to have documentation as listed in schedule 2 on staff personal files. Evidence is required to demonstrate that reconciliation of service users personal finances and accounts correspond. The registered person is required DS0000026444.V288117.R01.S.doc Timescale for action 16/08/07 2 OP9 13 (2) 30/06/07 3. OP15 16 (2) 16/07/06 4 OP29 19(1) 16/07/06 5. OP35 20 (1) 16/08/06 6 OP38 13 (4c) 23/06/06 Page 24 Hazelgrove Care Home Version 5.1 to ensure appropriate risk assessments are in place with regards to the hot water temperatures to ensure service users are fully protected. 7 OP38 23(2b) The responsible individual is required to forward a copy of the competed mains electrical testing to demonstrate it has been completed satisfactorily. 16/07/06 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 Hazelgrove Care Home DS0000026444.V288117.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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 Hazelgrove Care Home DS0000026444.V288117.R01.S.doc Version 5.1 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. 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!