Inspection on 01/10/07 for Hazelgrove Court Nursing Home

This inspection was carried out on 1st October 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Hazelgrove Court Nursing Home 22/07/09

Hazelgrove Court Nursing Home 26/09/06

Hazelgrove Court Nursing Home 28/11/05

Hazelgrove Court Nursing Home 10/05/05

Hazelgrove Court Nursing Home 22/02/05

Hazelgrove Court Nursing Home 22/06/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Hazelgrove Court Nursing Home Randolph Street Saltburn-by-Sea TS12 1LN Lead Inspector Jane Bassett Key Unannounced Inspection 1st October 2007 09:30 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 Court Nursing Home DS0000000173.V351792.R02.S.doc Version 5.2 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 Court Nursing Home DS0000000173.V351792.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hazelgrove Court Nursing Home Address Randolph Street Saltburn-by-Sea TS12 1LN 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) 01287 625800 Premier Nursing Homes Limited Position Vacant Care Home 48 Category(ies) of Dementia - over 65 years of age (24), Old age, registration, with number not falling within any other category (24), of places Physical disability over 65 years of age (0) Hazelgrove Court Nursing Home DS0000000173.V351792.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. To allow the admission of upto 3 people with a Physical Disability (PD) aged 55 years plus. To allow the admission of upto 3 people with Dementia aged 55 years plus. To allow the admission of one named individual who is under the age category to reside in the home. The Manager (Mrs Lesley Smith) should attain a relevant Management qualification by 2005. Manager (Mrs Lesley Smith) to attain the `Caring for people with Dementia` course or equivalent within 1 year of registration. 26th September 2006 Date of last inspection Brief Description of the Service: Hazlegrove is a 48-bedded care home providing both personal and nursing care. The home offers single room accommodation, which meets with the national minimum standards as to size. All rooms have en-suite toilet facilities. The home is operated as two specific units; on the ground floor the home provides care for 24 older people with physical disabilities; on the first floor care is provided for 24 older people with dementia. The home is situated in Saltburn close to the town centre and sea front; it is close to local shops and amenities. The ownership of the home has very recently changed, however the home will continue to operate as Premier Nursing Homes Ltd. The home charges fees that range from £430.04 to £569.08, depending on level of care provided. Hazelgrove Court Nursing Home DS0000000173.V351792.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection report includes information obtained from an Annual Quality Assurance Assessment (AQAA) completed by the area manager for the home. Two visits to the home were carried out, the first visit was unannounced. During the visits, which lasted seven hours the inspector walked around the building and looked at documentation including staff records and residents files. The inspector spoke to two residents, two visitors, six staff members, the manager and the area manager. As the inspector walked around the home she carried out indirect observation of interactions between residents and staff. One resident and three staff returned surveys to CSCI. The manager has recently taken up the position, the previous manager left the care home in June 2007. What the service does well: What has improved since the last inspection? A suitable lock has been fitted to the laundry door as required at the previous inspection. During this inspection it was seen that action is being taken to improve the facilities used for the storage of medication. The manager has initiated a system to record that suitable recruitment checks have been carried out by an agency for any staff supplied to work at the home. It was also noted on the second day of the inspection that an assessment of pressure care had been carried out by a tissue viability nurse employed by the company. Hazelgrove Court Nursing Home DS0000000173.V351792.R02.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Hazelgrove Court Nursing Home DS0000000173.V351792.R02.S.doc Version 5.2 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 Court Nursing Home DS0000000173.V351792.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Outcomes for standard 3 were looked at. People who use the service experience good quality outcomes in this area. Prospective people who use a service and their representatives have the information needed to choose a home, which will meet their needs. They have their needs assessed. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: During the inspection two files of residents recently admitted were examined. Both were seen to contain evidence of an assessment of need carried out prior to the admission of that person. One person who spoke to the inspector told her they had the opportunity to look around the home prior to admission. The home does not offer intermediate care. Hazelgrove Court Nursing Home DS0000000173.V351792.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Outcomes for standards 7, 8, 9, & 10 were looked at. People who use the service experience good quality outcomes in this area. The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: During the inspection four residents files were examined. Each were seen to contain assessment documentation including activities of daily living, moving and handling, falls risk assessment, general risk assessment, and nutrition assessment. All files contained plans of care for identified needs, including day and night care plans, however these would benefit from further development to include details of the residents capabilities and preferences. The majority of the care plans were reviewed on a regular basis, however one had not been reviewed for 2 months. Another plan had large time gaps in evaluation and not reviewed as stated within the plan. The files also contained pen pictures including social and family history and daily records. Hazelgrove Court Nursing Home DS0000000173.V351792.R02.S.doc Version 5.2 Page 10 Documentation seen indicated residents are seen by the GP, dietician, district nurse and other health professionals as needed. Whilst the files contained information on the care needs of the resident and how these are to be met, the inspector found the documentation confusing. Staff who spoke to the inspector also commented on the documentation, one said ‘there is sufficient information but the files are is confusing’. The manager stated an audit is to be carried out and new documentations to be introduced. Staff who spent time with the inspector were able to demonstrate through response to questions a good knowledge of individual residents, their needs and how these are met. The home operates a named nurse and key working system. On the second visit the inspector was shown evidence that an audit of pressure area damage had taken place. This had been carried out by a tissue viability nurse employed by company. The inspector was told all identified residents now had specific plans of care. And additional equipment had been ordered. All residents and relatives who spoke to the inspector were happy with the care they received. One relative said ‘carers really put themselves out to care’, another commented on staff being ‘supportive’. Relatives said they were involved in reviews and kept informed of any changes. The inspector observed good interaction and rapport between staff and residents, needs were seen to be addressed with respect. A Random sample audit of medication found no major concerns with, ordering, storage, recording, administration and disposal of medication. However it was seen on the first day of inspection, medication continued to be stored on open shelves in a walk in medication store. The inspector noted on the second day of inspection that internal storage cupboards had been fitted and were awaiting locks. A number of hand written entries of medication instruction recorded on administration sheets had only one signature. The inspector was told that medication is only administered by qualified nursing staff. Hazelgrove Court Nursing Home DS0000000173.V351792.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Outcomes for standards 12, 13, 14, & 15 were looked at. People who use the service experience good quality outcomes in this area. People who use services are able to make choices about their lifestyle and are supported by the staff. Social, cultural and leisure activities meet individual expectations. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: The home employs an activities Coordinator who enables residents the opportunity to participate in such things as bingo, dominoes, visits to the pub, and sing a longs. The inspector was told some people prefer not to join in and preferred to spend time in their own rooms. The inspector observed good interaction between staff and residents. All residents seen during the inspection appeared settled and comfortable in their surroundings. Staff who spoke to the inspector were able to describe how they promote choice and independence where possible. All spoke of respecting the privacy and dignity of residents. The residents files examined each contained a record of preferred activities. Relatives and residents who spoke to the inspector told her they were happy Hazelgrove Court Nursing Home DS0000000173.V351792.R02.S.doc Version 5.2 Page 12 with their own lifestyles. Visitors were made welcome and could meet with their relative in either the lounge or in the privacy of their own rooms. All who spoke to the inspector said the meals were ‘very good’ comments received included ‘the food is really great’ and ‘ there is a good choice’. Hazelgrove Court Nursing Home DS0000000173.V351792.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Outcomes for standards 16 & 18 were looked at. People who use the service experience good quality outcomes in this area. People who use the service are able to express their concerns and have access to an effective complaints procedure, are protected from abuse and have their rights protected. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: Information received in the AQAA submitted by the home indicated no complaints had been received in the previous 12 months. The inspector found the complaints policy was accessible to residents, relatives and staff. It was noted the procedure had been updated to reflect current contact details. The home has a system for recording any complaints it receives. Residents and relatives who spoke to the inspector told her they were aware of how to raise any issues. Staff who spoke to the inspector were able to demonstrate through response to questions the actions they would take in relation to any concerns. Records seen during the inspection indicated the majority of staff had undertaken training in relation to prevention of abuse and the ‘no secrets’ guidance. Hazelgrove Court Nursing Home DS0000000173.V351792.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Outcomes for standards 19 & 26 were looked at. People who use the service experience good quality outcomes in this area. The physical design and layout of the home enables people who use the service to live in a safe, well-maintained and comfortable environment. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: The four residents files examined during the inspection were seen to contain an environmental risk assessment for individual bedrooms. The inspector walked around the building on the first day of inspection. The home was found to be clean and generally odour free, however some equipment was seen to be stored in corridor areas. This had been removed by the second day of inspection. It was noted that a lock had been fitted to the laundry door as required at the previous inspection. Residents rooms seen by the inspector were personalised to taste with the residents own pictures, ornaments etc. Relatives who spoke to the inspector commented on the pleasant environment. Hazelgrove Court Nursing Home DS0000000173.V351792.R02.S.doc Version 5.2 Page 15 Information in the pre inspection questionnaire indicated the home is maintained as required. Hazelgrove Court Nursing Home DS0000000173.V351792.R02.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): Outcomes for standards 27, 28, 29, & 30 were looked at. People who use the service experience good quality outcomes in this area. Staff at the home are trained, skilled and generally in sufficient number to support the people who use the service. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: On the first day of the inspection the inspector was told there were 47 residents. A staffing rota seen on the day of the inspection indicated there were two qualified nurses and eight care staff on duty on the mornings, two qualified and six care assistance on the afternoon, two qualified nurses and seven care assistants on an evening and two qualified nurse and three care assistance overnight. The home has separate domestic, laundry and catering staff. Relatives who spoke to the inspector said there was generally sufficient staff, but at times they could be busy, for example meal times. Staff who spoke to the inspector told her they met the needs of the residents, however at times they were busy. The inspector examined the files of two staff recently recruited. Both were found to contain the required documentation. However the employment history on one application form gave year’s only and not complete dates. There were two written references in both files, however neither of the references in one file was from that person’s previous employer. Hazelgrove Court Nursing Home DS0000000173.V351792.R02.S.doc Version 5.2 Page 17 It was noted that some recruitment records, for example the application form, were completed on the documentation of another company, not Premier Nursing Homes Limited. On the first day of inspection the inspector was told that the home has used agency staff to cover a number of shifts, at that time there were no records of confirmation of satisfactory recruitment checks carried out by the agency supplying the person. These were obtained and made available on the second day of inspection. Information included in the AQAA submitted by the home and a sample audit of staff files and other documentation indicated staff have received induction training and further training including moving and handling, fire safety, first aid, prevention of abuse and health and safety training. The inspector was told further training is planned The inspector was told 33 of care staff have completed NVQ at level 2 or above. Relatives who spoke to the inspector all expressed satisfaction with the attitude and approach of the staff, one person commented on the ‘ dedicated staff team’. Hazelgrove Court Nursing Home DS0000000173.V351792.R02.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): Outcomes for standards 31, 33, 35, & 38 were looked at. People who use the service experience good quality outcomes in this area. The management and administration of the home is based on openness and respect. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: The previous manager left in June 2007. Staff at the home have been supported by the area manger until the recent appointment of the new manager. Staff who spoke to the inspector told her communication was generally good, there have been recent staff meetings and there is a hand over of information at the start of each shift. Staff also said they have received supervision. Staff who spoke to the inspector said there were regular visits to the home by the area manager and operations director. The inspector was told that the report Hazelgrove Court Nursing Home DS0000000173.V351792.R02.S.doc Version 5.2 Page 19 from these visits were to be developed and outcomes feedback to the service users. Relatives told the inspector they were ‘kept informed’ and had the opportunity to attend meetings. Another said they had been asked to complete a quality survey earlier in the year. Information contained in the AQAA received by CSCI indicated the home and the equipment were maintained as required. The inspector evidenced a record of fire tests, and drills, however the documentation was seen to be disorganised. The home has a range of policies and procedures that were reviewed in June 2007. Accidents were seen to be recorded. However the accident analysis, care planning audit and medication audit were not up to date. The new manager told the inspector that she had commenced an audit of all the systems used in the home. During the inspection it was found that an incident affecting a service user had not been reported to CSCI as required. The inspector was told the home does not handle any personal monies for residents, all expenditure is invoiced. Hazelgrove Court Nursing Home DS0000000173.V351792.R02.S.doc Version 5.2 Page 20 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 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 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 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 X 3 Hazelgrove Court Nursing Home DS0000000173.V351792.R02.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? No 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 (2) (b) Requirement Plans of care must be reviewed and evaluated as required to reflect the person’s current needs. A full employment history must be obtained and any gaps in employment investigated, prior to employment. References must be where ever possible obtained from the persons previous employer, prior to employment. The registered person must ensure that CSCI are notified of all incidents affecting the well being of service users. Timescale for action 01/12/07 2 OP29 19 01/12/07 3 OP29 19 01/12/07 4 OP33 37 01/11/07 Hazelgrove Court Nursing Home DS0000000173.V351792.R02.S.doc Version 5.2 Page 22 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 Refer to Standard OP7 OP9 Good Practice Recommendations Plans of care would benefit from further development to include the person’s capabilities and preferences. Handwritten entries on the MAR charts should be signed, dated and countersigned to reduce the risk of mistakes when copying information from the pharmacy label or prescription. The security of medication storage would benefit from the provision of locks to internal storage cupboards and security bars to windows. Records including care plan documentation and fire drills would benefit from further devolvement and organisation to make them less confusing. Training should continue to ensure the home employs a minimum of 50 care staff who have achieved NVQ at level 2 or above. The manager should submit an application for registration to CSCI. Work should continue to develop the quality assurance systems within the home. All documentation used within the home should reflect the company registered with CSCI as owning and operating the home. 3 4 5 6 7 8 OP9 OP7 OP33 OP30 OP31 OP33 OP37 Hazelgrove Court Nursing Home DS0000000173.V351792.R02.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Court Nursing Home DS0000000173.V351792.R02.S.doc Version 5.2 Page 24 - 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!