Inspection on 10/05/05 for Hazelgrove Court Nursing Home

This inspection was carried out on 10th May 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.

Other inspections for this house

Hazelgrove Court Nursing Home 22/07/09

Hazelgrove Court Nursing Home 01/10/07

Hazelgrove Court Nursing Home 26/09/06

Hazelgrove Court Nursing Home 28/11/05

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 Hazlegrove Court Randolph Street Saltburn-by-Sea Address 3 TS12 1LN Lead Inspector Jane Bassett Unannounced 10 May 2005 10:00 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. Hazlegrove Court CS0000000173.V225424.R01.doc Version 1.30 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 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 Mrs Lesley Smith Care Home 48 Category(ies) of DE(E) Dementia - over 65 (24), PD (E) Physical registration, with number Disability - over 65 (0), OP Old Age (24) of places Hazlegrove Court CS0000000173.V225424.R01.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: No conditions of registration. Date of last inspection 22/02/05 Brief Description of the Service: Hazlegrove is a 48-bedded care home providing both personal and nursing care. The home offers single room accomodationwhich 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. Hazlegrove Court CS0000000173.V225424.R01.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. During the inspection the inspector spoke to 2 residents, 3 families, 4 staff and the manager of the service. Documentation including plans of care, and staff records were examined. A total of 6.5 hours were spent at the home. It was not possible to get feedback from the majority of the residents due to their capabilities and frailty, however the inspector noted that all appeared settled and comfortable in their surroundings. What the service does well: What has improved since the last inspection? What they could do better: Hazlegrove Court CS0000000173.V225424.R01.doc Version 1.30 Page 6 Further development work is required with regard to the risk assessment documentation with regard to the use of bed rails. The home must also ensure that risk assessments are completed for all areas of risk identified. Risk assessment must be comprehensive and include the agreement of all parties involved in the decision. There must be on going assessment and evaluation of all needs identified to ensure that residents receive the appropriate care. 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. Hazlegrove Court CS0000000173.V225424.R01.doc Version 1.30 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 Hazlegrove Court CS0000000173.V225424.R01.doc Version 1.30 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, 4 & 5 The admission procedure carried out by the home was found to include assessment of care needs for individual residents. Residents and families spoken to confirmed that the home ensures that care needs can be met. EVIDENCE: During the inspection 3 residents individual plans of care were examined for evidence of pre admission information gathering. All were found to contain records of information regarding residents care needs including evidence of assessment by staff at the home and those carried out by the residents social worker. Residents and families who spoke to the inspector confirmed that they had the opportunity to visit the home and discuss care needs prior to admission. All who spoke to the inspector indicated that their needs were met. One family spoke of the manager visiting their relative in hospital to introduce herself and gather information. Hazlegrove Court CS0000000173.V225424.R01.doc Version 1.30 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, &10. Residents who were able and families who spoke to the inspector were positive and satisfied with the care that they receive. Some progress has been made to ensure that residents continuing health care needs and risk assessments are recorded and met, however work needs to continue to ensure that these are provide for all residents as required. Without this there is no assurance that all care needs will be met. EVIDENCE: Documentation seen in 3 residents care plans examined showed that documentation included evidence of risk assessments, plans of care and evaluation. Risk assessments with regard to use of bed rails continue to require further development. The manager told the inspector that the home is using a consultant for this purpose and ongoing development is taking place. Two residents files examined did not contain specific risk assessments that had been discussed and agreed with families in relation to concerns highlighted in other documentation. Specific risk assessments seen in other residents files contained evidence of agreement with families. Hazlegrove Court CS0000000173.V225424.R01.doc Version 1.30 Page 10 Evidence was also seen that indicated plans of care had been discussed and agreed with residents or their representatives, however one set of documents contained little information with regard to the continuing assessment and evaluation and therefore did not reflect the residents current needs. Residents and families spoken to all expressed their satisfaction with the care received and the friendly but respectful attitude of all of the staff at the home. They were able to confirm that individual care needs have been discussed and agreed with them. One visitor spoke of the support that they had received from the staff and the ‘good care’ her relative received, another described the service as ‘excellent’. One resident said that the staff ’care for me well’ and were very obliging. Residents who were able confirmed that their privacy, rights and choices were respected by all the staff and that they set their own daily routines. They confirmed that they had access to their own GP’s and other health professionals as required. The inspector observed a good interaction and rapport between staff and residents, needs were seen to be addressed with respect. Hazlegrove Court CS0000000173.V225424.R01.doc Version 1.30 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 ,13 & 14 Social activities are available for those who wish to participate and socialise. Visitors are encouraged and welcome. EVIDENCE: Two residents who spoke to the inspector confirmed that they have choice in all areas of daily living. Staff support them to maintain their independence, one resident spoke positively of the ‘individual care’ received. Relatives who spoke to the inspector commented on the increased amount and variety of activities that are taking place. One relative commented on the individual approach of the activities co-ordinator to the residents. One visitor and one resident spoke of the variety of activities that were available, including some craft work and games. Another visitor told the inspector that the variety included the activities co-ordinator bringing in a rabbit to allow the residents a chance to stroke and pet it. Staff and visitors confirmed that there was contact with churches as requested. All who spoke to the inspector confirmed that there was always a friendly welcome at the home and visiting was at any time. Hazlegrove Court CS0000000173.V225424.R01.doc Version 1.30 Page 12 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 & 18 Staff demonstrated a commitment to the protection of the residents that they care for. Complaints are handled and documented in such a way as to promote objectivity and confidence in the process. EVIDENCE: The home had a record of complaints received , this was found to include details of investigation, any actions taken and response to the complainant. The complaints procedure was seen to be accessible to residents and families. One family member spoke of her satisfaction to a concern raised by herself, she said that she was happy with both the reaction of the staff and the outcome of the issue. Other families confirmed that they were aware of how to raise any concerns. The home has a policy and procedure in relation to protection of vulnerable adults, however this continues to require further development, as recommended at the previous inspection, as it does not fully follow the order of action to be taken as required in the ‘no secrets’ guidance. All staff spoken to were aware of the actions that would be taken should a concern be identified and were able to demonstrate a commitment to protecting residents safety and wellbeing. Hazlegrove Court CS0000000173.V225424.R01.doc Version 1.30 Page 13 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 & 26 The home continues to be well maintained, it was found to be clean and odour free, providing a pleasant environment for residents. EVIDENCE: The home was found to be clean, tidy and odour free. Residents and families spoken to all expressed satisfaction with the environment. Decoration was seen to be well maintained. Staff who spoke to the inspector said that there were not aware of any health and safety issues. Records seen indicated that hot water temperatures of all bathing outlets are checked and recorded more frequently as recommended at the previous inspection. Residents bedrooms which were seen were found to be personalised with pictures and ornaments. Hazlegrove Court CS0000000173.V225424.R01.doc Version 1.30 Page 14 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) 27 & 29 Staffing provided by the home was sufficient to meet the current needs of the residents. Improvements have been made with regard to information gathered as part of the recruitment process making this a more robust procedure. EVIDENCE: Residents and families spoken to said that there were sufficient staff to meet their needs, but staff were always busy. One resident commented on the prompt response of staff to the call bell, stating that ‘they care for me well’ and ‘always accommodate my wishes’. One family who spoke to the inspector said that their relative was ‘looked after as well as they can’. Another family commented on the ‘marvellous’ response of staff. Staff spoken to confirmed that they had sufficient time to meet resident’s needs. Three staff files were seen in relation to recruitment these were found to contain the appropriate information. One file of a care assistant currently being recruited contained an application form which contained evidence of dates of previous employment and two references, one of which was from previous employer as recommended at the previous inspection. Hazlegrove Court CS0000000173.V225424.R01.doc Version 1.30 Page 15 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) 31 & 33 The managerial style promotes an open and positive atmosphere. EVIDENCE: The manager of the home has the appropriate nursing qualifications and is to undertaken her NVQ level 4 in management. Residents, family and staff made positive comments about the staff team, good communication and support given by the manager. The proprietor carries out regulation 26 visits and supplies copies of these to the Commission for Social Care Inspection. Hazlegrove Court CS0000000173.V225424.R01.doc Version 1.30 Page 16 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 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 x COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 2 x 3 x x x x x Hazlegrove Court CS0000000173.V225424.R01.doc Version 1.30 Page 17 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. 2. Standard 7 7 Regulation 13 15 Requirement Risk assessments with regard to use of bedrails require further . ( timescale of 01/04/05 not met) Plans of care and assessments must reflect residents current needs. ( timescale of 1st May 2005 not met) Plans of care must include assessments for specific risks identified. The manager must obtain her NVQ level 4 qualification or by end 2005. Timescale for action By 1st July 2005 By 1st July 2005 By 1st July 2005 31st December 2005. 3. 4. 7 31 13 9 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 18 Good Practice Recommendations The policy on prevention of abuse should be developed to reflect the order of action required in the no secrets guidance. Hazlegrove Court CS0000000173.V225424.R01.doc Version 1.30 Page 18 Commission for Social Care Inspection Unit B - Advance St Marks Court Teesdale Stockton-on-Tees. TS17 6QX 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 Hazlegrove Court CS0000000173.V225424.R01.doc Version 1.30 Page 19 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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