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Inspection on 19/07/05 for Hazelgrove Care Home

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

This inspection was carried out on 19th July 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 staff at Hazelgrove promote a welcoming and caring environment, service users spoke highly of staff and stated that they do anything to try and accommodate their needs; they are respectful and uphold privacy. The care planning techniques of staff is at a good standard and ensures service users complex needs are met; this will be further promoted with the intended new package being implemented at present.

What has improved since the last inspection?

Since the last inspection service users and relatives have been consulted with regards to room keys, the findings of which were available for inspection. The regional manager is now researching so appropriate keys can be purchased and fitted ensuring service users have added privacy and security. The dining room furniture is to be replaced and a representative was visiting the home on the day of the inspection, this will promote a more homely environment for service users.

What the care home could do better:

There remains one outstanding requirement from the previous inspection with regards to smoking arrangements, which needs attention to ensure serviceusers rights are not infringed upon. Risk assessments and recruitment practices require further attention to ensure service users are fully protected. Records whilst generally at a good standard require attention to ensure they are up to date and accurate so service users best interest are promoted.

CARE HOMES FOR OLDER PEOPLE Hazelgrove Care Home 1a Farleys Lane Hucknall Nottingham NG15 6DY Lead Inspector Karmon Hawley Unannounced 19/07/05 10.00am 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. Hazelgrove Care Home C03 C53 S26444 Hazelgrove V238551 190705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Hazelgrove Care Home Address 1a Farleys Lane Hucknall Nottingham NG15 6DY 0115 9680706 0115 9680706 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) Mr G Hudson CRH 40 Category(ies) of OP 40 registration, with number DE/E 10 of places PD 2 TI 2 Hazelgrove Care Home C03 C53 S26444 Hazelgrove V238551 190705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: NONE Date of last inspection 23rd Febuary 2005 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; non of which have ensuite facillities. It is situated near to a doctors surgery, within half a mile of shops, a public house, cinema, library, tourist sights and other local amenties 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 serive 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 pallative care. Hazelgrove Care Home C03 C53 S26444 Hazelgrove V238551 190705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over one day. Six service users case files, four staff personnel files and other related records with regards to the care and environment were examined. Two relatives, two staff members and four service users were spoken with. The administrator initially assisted with the inspection until the regional manager arrived who then continued with the inspection process with the inspector. What the service does well: What has improved since the last inspection? What they could do better: There remains one outstanding requirement from the previous inspection with regards to smoking arrangements, which needs attention to ensure service Hazelgrove Care Home C03 C53 S26444 Hazelgrove V238551 190705 Stage 4.doc Version 1.40 Page 6 users rights are not infringed upon. Risk assessments and recruitment practices require further attention to ensure service users are fully protected. Records whilst generally at a good standard require attention to ensure they are up to date and accurate so service users best interest are promoted. 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 C03 C53 S26444 Hazelgrove V238551 190705 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 Hazelgrove Care Home C03 C53 S26444 Hazelgrove V238551 190705 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) 3,5 Service users can be assured their needs will be fully assessed and met and opportunity is given to visit the home and make an informed choice. EVIDENCE: Relatives and prospective service users are invited to visit the home prior to admission. The administrator and a senior carer visit prospective service users in the community to carry out pre admission assessments. Emergency and respite care is offered and if possible the same procedure followed. If a service user were unhappy with the placement no restrictions would be placed upon them to stay. One relative stated she had received all necessary paperwork prior to her mother entering the home. Hazelgrove Care Home C03 C53 S26444 Hazelgrove V238551 190705 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) 7,8,9,10 Service users plans of care ensure needs will be met, however current risk assessments may leave service users at a degree of risk. Service users can be assured their health care needs will be fully met; medication dealt with appropriately and that they are treated with respect and their right to privacy will be upheld. EVIDENCE: A new care-planning package has been devised which is in depth and aimed at improving care, this will commence immediately with all new admissions and will be introduced gradually to those presently in the home. Care plans examined were based upon the daily activities of daily living and were underpinned by information extracted from assessments that take place with regards to manual handling, nutrition and pressure area care. Care plans demonstrated individuality and addressed complex needs. Appropriate risk assessments were in place however these did not cover the risk of entrapment for the use of bed rails and the risk from hot water. Daily records were maintained were in depth and covered significant events. Hazelgrove Care Home C03 C53 S26444 Hazelgrove V238551 190705 Stage 4.doc Version 1.40 Page 10 There was evidence of specialist services being liaised with and there are link staff within the home to enhance these services. Specialist equipment and aids were available. Medication procedures were inspected and were satisfactory on the day of inspection. Medications and prescriptions were checked and they corresponded. If private visits are required the service user may use their own room the dining room or the little lounge. 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. There are no restriction on visiting times. Hazelgrove Care Home C03 C53 S26444 Hazelgrove V238551 190705 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) 12,15 Service users are enabled to live a lifestyle that will meet their expectations and preferences. Whilst the menu on offer is exceptional, service users are placed at a degree of risk due to the lack of monitoring and recording in the safe storage and delivery of food. EVIDENCE: A flexible routine is enhanced and service users can choose when to get up and retire to their rooms. An activities coordinator is employed fulltime and a diverse range of activities is available. The activities coordinator has completed the age concern activities coordinator course and is currently adapting this in her practice by implementing social care planning. Service users were able to substantiate that activities take place. Bedrooms are personalised and service users may bring in possessions as they wish. 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 gaps within cleaning rotas, food temperature probing and storage temperatures. The dining chairs remain as previous; plastic garden furniture, however a representative was visiting on the day of inspection to consider more suitable furniture. Hazelgrove Care Home C03 C53 S26444 Hazelgrove V238551 190705 Stage 4.doc Version 1.40 Page 12 One service users expressed she would like a lock on her bedroom door; this is currently being researched to find suitable locks. Hazelgrove Care Home C03 C53 S26444 Hazelgrove V238551 190705 Stage 4.doc Version 1.40 Page 13 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 Service users have the opportunity to express complaints, however these may not in all cases be acted upon and resolved appropriately. EVIDENCE: An ideas, suggestions, plaudits and complaints book is located in the main entrance and an appropriate policy is in place. One plaudit had been received which was of a very positive nature regarding care delivered. Two complaints had been received since the last inspection, the regional manager stated that she currently looks into complaints received and the nature of the complaint, action and outcome would be noted. Hazelgrove Care Home C03 C53 S26444 Hazelgrove V238551 190705 Stage 4.doc Version 1.40 Page 14 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 Whilst service users live in a safe, well-maintained environment, the rights of non-smokers may be infringed upon due to current smoking arrangements. EVIDENCE: A maintenance man is employed who tends to both the external grounds and internal environment, which were well maintained. There is an ongoing maintenance and redecoration plan in place. There is a reception room, lounge, dining room and a smoke room/library room, which remains open plan. Hazelgrove Care Home C03 C53 S26444 Hazelgrove V238551 190705 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) 29,30 Service users protection is currently compromised due to the recruitment practices in place. Service users can be assured staff are trained and competent to do their job. EVIDENCE: Staff personnel files were observed, required documentation was in place however one registered nurses personal identification number was not available as evidence and had not been checked as effective, also a registered nurses visa details did not correspond with the employer details. Each staff member has a personal training plan, which demonstrated that mandatory and additional training is taking place. The induction is under review as it is basic at present. Service users spoke highly of staff and stated that if they ask for anything staff try to accommodate this, they are respectful and uphold privacy. Staff spoken with were able to discuss core values and principles and demonstrate knowledge with regards to service users in their care. Hazelgrove Care Home C03 C53 S26444 Hazelgrove V238551 190705 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) 33,37,38 Health safety and welfare of service users is promoted, however this may be compromised due to the lack of risk assessments and noted deficits in record keeping. Quality audits ensure the home is run in the best interest of the service users. EVIDENCE: All maintenance checks and servicing checks had taken place and were satisfactory. Weekly health and safety checks for radiators, hot and cold water are carried out. Risk assessments have been completed with regards to hot water as this is delivered throughout the home at between 53 – 60 oC, however these were not available for inspection. Quality assurance questionnaire are currently being developed. Questionnaires have been sent to the multidisciplinary team and will be collated and published. The regional manager is currently updating the quality manual. Hazelgrove Care Home C03 C53 S26444 Hazelgrove V238551 190705 Stage 4.doc Version 1.40 Page 17 Records are kept in accordance with the data protection act, however the records for the kitchen were not up to date and relevant checks had not been undertaken for all staff. Hazelgrove Care Home C03 C53 S26444 Hazelgrove V238551 190705 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 x x 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 2 COMPLAINTS AND PROTECTION 3 2 x x x x x x STAFFING Standard No Score 27 x 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 x x x 3 x x x 2 2 Hazelgrove Care Home C03 C53 S26444 Hazelgrove V238551 190705 Stage 4.doc Version 1.40 Page 19 yes Are there any outstanding requirements from the last inspection? 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 13 (4c) Requirement The registered person is required to ensure appropaite risk assessments are in place to ensure service users are fully protected. The registered person is required to ensure the safe handling, storage, preparation and serving of food. The registered person is required to reconsider the smoking arrangements to ensure service users rights are not infringed upon. This is an outstanding requirement and must be addressed to avoid enforcement action. The registered person is required to ensure appropriate recruitment policies and procedures are in place to fully protect service users The registered person is required to ensure all records are maintained and up to date. Timescale for action Immediate 2. OP15 16 (2) 30th August 2005 Immediate 3. OP20 12(3) 4. OP29 19(1) 30th August 2005 5. 6. OP37 17(3a,b) 30th August 2005 Hazelgrove Care Home C03 C53 S26444 Hazelgrove V238551 190705 Stage 4.doc Version 1.40 Page 20 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 Good Practice Recommendations Hazelgrove Care Home C03 C53 S26444 Hazelgrove V238551 190705 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection Edgeley House 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. 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