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Inspection on 20/12/05 for Hazelgrove Care Home

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

This inspection was carried out on 20th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 are well looked after and staff are respectful and uphold privacy. It was obvious during the inspection that a good rapport is maintained between staff and service users. Service users are looking forward to Christmas and have enjoyed the range of activities that have been arranged.

What has improved since the last inspection?

The care package has continued to be implemented and developed, once completed this will provide a good standard of documentation. The Administration Manager has discussed smoking arrangements with service users to ensure rights are not infringed upon and further consideration is still being given to the smoking policy. The homes kitchen staff are completing all required documentation ensuring the safety of service users. Staff training has continued to improve and develop thus ensuring staff are competent and trained to carry out their job role.

What the care home could do better:

Further work is required to complete the new care planning documentation, whilst it is appreciated this takes time it is advisable to use only one folder as important information may be missed due to the current system in use. Care planning requires attention to ensure all identified needs are documented thus met. Risk assessments are in need of attention to ensure management plans are in place to ensure service users are fully protected. Recruitment and selection procedures require immediate attention to ensure service users are fully protected. Additional consideration to the management of service users personal finances is required to ensure these are fully safeguarded. To ensure service users remain safe at all times proactive management plans are required to ensure the relevant checks take place when agency catering staff are working in the home.

CARE HOMES FOR OLDER PEOPLE Hazelgrove Care Home 1a Farleys Lane Hucknall Nottingham NG15 6DY Lead Inspector Karmon Hawley Unannounced Inspection 20th December 2005 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.V267801.R03.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.V267801.R03.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.V267801.R03.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 19th July 2005 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. Hazelgrove Care Home DS0000026444.V267801.R03.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place in one day and was performed by one inspector. The main method of inspection 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. Five service users were spoken with so as to give the inspector an insight into the conditions and standards within the home. Those service users spoken with were happy with the care received and the standards within the home. The administrator and general care and development manager assisted in the inspection process and two members of staff were spoken with. Staff were able to demonstrate a good understanding of service users needs and the core values and principles in relation to their job role. What the service does well: What has improved since the last inspection? The care package has continued to be implemented and developed, once completed this will provide a good standard of documentation. The Administration Manager has discussed smoking arrangements with service users to ensure rights are not infringed upon and further consideration is still being given to the smoking policy. The homes kitchen staff are completing all required documentation ensuring the safety of service users. Hazelgrove Care Home DS0000026444.V267801.R03.S.doc Version 5.1 Page 6 Staff training has continued to improve and develop thus ensuring staff are competent and trained to carry out their job role. 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. Hazelgrove Care Home DS0000026444.V267801.R03.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 Hazelgrove Care Home DS0000026444.V267801.R03.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): EVIDENCE: Not assessed during this inspection. Hazelgrove Care Home DS0000026444.V267801.R03.S.doc Version 5.1 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 the following standard(s): 7 Whilst new care plan packages are being implemented service users needs may not be fully set out in the plan of care and confusion may arise due to the methods currently employed. Service users may be placed at a degree of risk due to the lack of risk management plans and their needs may not be fully met as needs may not be identified within the care plan. EVIDENCE: Four service users files were examined and demonstrated that the new packages are being implemented in order to improve the care plans in place. Service users undergo various assessments with regards to the daily activities of living, manual handling, falls, nutrition and infection; information gained from these form the basis of the plan of care. As care plans were being transferred two files were in use for two service users, due to this some assessments were only partly completed and it was difficult to establish up to date information. Within one file, a recent admission, assessments had not been fully completed. Not all identified needs had a plan of care in place, of which falls and diabetes were among them, however plans that were in place were personalised and reflected choices and preferences. Also despite risks being identified management plans were not in place to reduce these risks. Hazelgrove Care Home DS0000026444.V267801.R03.S.doc Version 5.1 Page 10 Daily records were not maintained in all files and it was difficult to establish the frequency of contact for each service user. Hazelgrove Care Home DS0000026444.V267801.R03.S.doc Version 5.1 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 the following standard(s): 13,14,15 Service users may exercise choice and control over their lives and maintain contact with relevant others. Proactive management plans are required when the home uses the catering company to ensure all relevant checks takes place to ensure service users remain safe at all times. EVIDENCE: There are no restrictions imposed upon visiting and service users spoken with substantiated this. 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. Visitors were seen to visit the home throughout the inspection and staff interacted well with them and were seen to make them welcome. All consultations are carried out in private in service users own rooms or the medical room if appropriate. One service user deals with his 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 two service users currently are using this service. Service users are encouraged and facilitated to bring in personal possessions. Due to the requirement set at the previous inspection the food, fridge and freezer temperatures and cleaning records were observed. The cleaning Hazelgrove Care Home DS0000026444.V267801.R03.S.doc Version 5.1 Page 12 records were satisfactory, however the fridge, freezer and food temperatures had not been recorded when agency staff had been working in the kitchen. Normal practice indicated and was evidenced that the regular cook does daily recording of temperatures. This was discussed during the inspection and the catering company contacted. Hazelgrove Care Home DS0000026444.V267801.R03.S.doc Version 5.1 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 the following standard(s): 18 Service users are protected from abuse however this may be compromised due to the recruitment procedures in place. EVIDENCE: Relevant policies and procedures are in place with regards to adult protection and staff have received training in this area and were able to discuss it appropriately. Two staff members employed as kitchen assistants were found not to have current protection of vulnerable adult checks, criminal record bureau checks or references in place. The Administration Manger stated these would have been done at head office and she would contact them with regards to the outcome of the protection of vulnerable adult checks, however although staff were under supervision there was no policy in place with regards to supervised practice whilst waiting for criminal records checks to be completed. Service users expressed no concerns and two of those spoken with stated that staff were approachable and they felt comfortable to approach them and discuss any concerns if they arose. Hazelgrove Care Home DS0000026444.V267801.R03.S.doc Version 5.1 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 the following standard(s): 26 The home is clean, pleasant and hygienic. EVIDENCE: The home on the day of the day of inspection was clean and hygienic. There are sufficient hand wash facilities throughout the building and laundry facilities in place to meet the required standards. Staff have received training in infection control and each service user undergoes a risk assessment with this regard. The laundry assistant was able to discuss how dirty or infective linen is handled satisfactory. Hazelgrove Care Home DS0000026444.V267801.R03.S.doc Version 5.1 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 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): The number and skill mix of staff meets service users needs and service users are in safe hands at all times. Further consideration with regards to younger workers and the Working Time Regulations 1998 is recommended to ensure younger staff members rights are highlighted and maintained. EVIDENCE: The staff rotas were observed and demonstrated sufficient staff were employed. The administrator stated that skill mix is considered when preparing the duty rota. Staff spoken with stated that sufficient staff are on duty to meet service users needs. There are three members of staff employed under the age of 18; there was no policy in place with regards to younger workers. Service users spoken with stated that staff were available to meet their needs. Nine members of staff have attained the national vocational qualification in care level two, two staff are currently working towards this qualification and four are working towards level three. An appropriate induction programme is available for all new members of staff. Hazelgrove Care Home DS0000026444.V267801.R03.S.doc Version 5.1 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 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): 31,35 Staff are supported by the current management arrangements and the home is run in the best interest of service users, further attention to this standard is required at the next inspection as it was not fully inspected. Service users financial interests may be compromised due to the current systems in place with regards to the handling of personal allowances. EVIDENCE: The current manager of the home is looking towards ceasing this role; therefore, active and thorough selection process continues to take place to find an appropriate person to take over this role in the near future. The General Care and Development Manager visits the home twice a week in order to support the manger. Staff stated they felt supported in their job role, care was consistent and at a good standard. This standard was therefore not fully inspected and further attention is required at the next inspection Hazelgrove Care Home DS0000026444.V267801.R03.S.doc Version 5.1 Page 17 Service users may use the facility of safe holding of their personal allowances should they wish. Each service user has an individual accounting book, which demonstrates transactions taking place, however none of these were signed for. A main bank account is used for service users money and also a float in a tin kept at the home. Service users may use money even if they do not have any, thus going into deficit; relatives are then invoiced for money. Interest accrued on the bank account is used for instance to clear bills should a service user pass away owing money. The administrator states she occasional checks amounts in service users books, the bank account and the tin to ensure it corresponds, however there was no evidence of this audit trail. Hazelgrove Care Home DS0000026444.V267801.R03.S.doc Version 5.1 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 1 X X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 2 X X X Hazelgrove Care Home DS0000026444.V267801.R03.S.doc Version 5.1 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 Standard OP7 Regulation 15 Requirement The registered person is required to ensure appropriate plans of care are in place to ensure service users needs are fully met. The registered person is required to ensure appropriate risk assessments are in place to ensure service users are fully protected. This is an outstanding requirement and must be addressed to avoid enforcement action. The registered person is required to ensure the safe handling, storage, preparation and serving of food when agency staff are working in the home. A proactive management system is to be put into place to prevent the reoccurrence of this. The registered person is required to ensure appropriate recruitment policies and procedures are in place to fully protect service users. The General manager must contact the head office and ascertain POVA 1st checks have been DS0000026444.V267801.R03.S.doc Timescale for action 30/03/06 2. OP7 13 (4c) 20/12/05 3 OP15 16 (2) 27/12/05 4. OP29 19(1) 20/12/05 Hazelgrove Care Home Version 5.1 Page 20 5 OP35 20 (1) made; the identified staff are to have no contact with service users in the mean time. A policy with regards to supervisory practice is to be implemented. The registered person shall not 30/03/06 pay money belonging to any service user into a joint bank account. Additional measures are to be implemented to ensure the safe transaction and monitoring of service users personal allowances. 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 2 3 Refer to Standard OP7 OP7 OP27 Good Practice Recommendations To provide a written entry in service users plans of care on a daily basis to demonstrate needs are met. To use one case file to minimise confusion and to ensure up to date/current information is available whilst the new care packages are being implemented. To implement a policy with regards to the younger worker to ensure safe working practices are maintained and relevant legislation is followed. Hazelgrove Care Home DS0000026444.V267801.R03.S.doc Version 5.1 Page 21 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.V267801.R03.S.doc Version 5.1 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. 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!