Inspection on 22/06/04 for Hazelgrove Court Nursing Home

Care Home For Older PeopleHazelgrove Court Nursing HomeRandolph Street Saltburn-by-Sea TS12 1LNUnannounced Inspection22nd June 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Hazelgrove Court Nursing Home Address Randolph Street, Saltburn-by-Sea, TS12 1LN Email address Name of registered provider(s)/company (if applicable) Premier Nursing Homes Limited Name of registered manager (if applicable) Mrs Lesley Smith Type of registration Care Home No. of places registered (if applicable) 48 Tel No: 01287 625800 Fax No:Category(ies) of registration, with (number of places) Dementia - over 65 years of age (24), Old age, not falling within any other category (24), Physical disability over 65 years of age (0) Registration number B010000102 Date first registered Date of latest registration certificate 31st May 2002 Was the home registered under the Registered Homes Act 1984? Do additional conditions of registration apply ? Date of last inspection 25th March 2004 YES YES 21/11/03 If Yes refer to Part CHazelgrove Court Nursing HomePage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 322nd June 2004 11.45 am Jane BassettID Code073878Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionNo Interpreter /signer Lynn Davey / Pat GwamandaHazelgrove Court Nursing HomePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: D.1. D.2. D.3. Compliance with Conditions (if applicable) Providers Response Providers Comments Action Plan Providers AgreementHazelgrove Court Nursing HomePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI), is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the CSCI in respect of Hazelgrove Court Nursing Home. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.Hazelgrove Court Nursing HomePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Hazlegrove is a 48-bedded care home providing both personal and nursing care. 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 home is operated by a company, Premier Care who have a further 3 homes in the north east of England.Hazelgrove Court Nursing HomePage 5 PART A SUMMARY OF INSPECTION FINDINGSINSPECTORS SUMMARY (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) On the day of the inspection staff within the home were helpful and welcoming. Interaction between service users and staff were seen to friendly but respectful. The home was found to be clean and generally odour free. Standards 1 to 6, Choice of Home. During the inspection 4 service users files were examined, each contained evidence of pre admission assessment and information gathering. The inspector was told that service users or their representatives are encouraged to visit the home prior to admission. Standards 7 to11, Health and Personal Care. Service users plans of care seen at the inspection contained evidence of assessment, care planning and reviews. Documentation seen also contained information on service users life histories and preferences. The inspector observed a good rapport and interaction between staff and service users. Staff were observed to deal with service users needs with respect and sensitivity. Service users who spoke to the inspector expressed their satisfaction with their lifestyle and the attitude and approach of the staff. Standards 12 to15, Daily Life and Social Activities. It was difficult to ascertain the views of the majority of the service users group due to their capabilities, however a number of service users and families who spoke to the inspector said they were happy with their lifestyle. Activities within the home are limited due to the service users capabilities. The home employs an activities co-ordinator and it was seen that a number of residents were involved in baking cakes. All expressed satisfaction with the activities and food provided by the home. Standards 16 to18, Complaints and Protection. Records seen on the day of the inspection indicate that complaints are recorded appropriately. The must make available to all staff a policy on prevention and reporting of abuse that includes reference to the `no secrets` guidanceHazelgrove Court Nursing HomePage 6 Standards 27 to 30, Staffing. On the day of the inspection it was found that the home was not meeting the required minimum staffing levels. A staffing rota was seen on the day of the inspection. This indicated that the home did not always comply with the agreed minimum staffing requirements as agreed with the previous authority. An immediate requirement notice was issued. Standards 31 to 38, Management and Administration. The manager has nursing qualifications and managerial experience, she is required to complete her NVQ level 4 in management or equivalent and dementia care qualification as agreed at her registration. Standards 19 to 26, Environment. On the day of the inspection the home was found to be pleasantly decorated, clean and generally odour free, however a number of service users bedrooms were found to have unpleasant odours. The lounges were observed to well used by service users. The gardens were well maintained.Hazelgrove Court Nursing HomePage 7 Requirements from last Inspection visit fully actioned? If No please list belowYESSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for actionAction is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations Standard 1 2 OP36 OP25 The registered person to formalise the supervision system in which all staff receive supervision six times a year. Hot water temperatures of all baths and showers should be checked on a weekly basis. Thermometers should be available in all bathrooms.CONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).Met (Yes / No)Hazelgrove Court Nursing HomePage 8 Hazelgrove Court Nursing HomePage 9 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action 1 16 OP4 The responsible person must ensure that there is sufficient appropriate equipment to meet service users needs. The responsible person must ensure that the home meets the minimum staffing levels as agreed with the previous regulatory authority. Action must be taken to remove unpleasant odours from a number of service users bedrooms. 1st September 2004. Immediate.218OP27323OP261st August 2004RECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * 1 2 OP36 OP25 The registered person to formalise the supervision system in which all staff receive supervision six times a year. Hot water temperatures of all baths and showers should be checked on a weekly basis. Thermometers should be available in all bathrooms. Page 10Hazelgrove Court Nursing Home 3 4OP18 OP31A policy and procedure regarding the prevention and reporting of abuse should be available to all staff. Manager to attain NVQ level 4 or equivalent in management and dementia care qualification as agreed at registration.* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. OP10 refers to Standard 10.Hazelgrove Court Nursing HomePage 11 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other (Specify) `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES YES NO YES YES NO YES NO YES YES YES NO YES YES NO NO NO YES NO YES 6 2 0 NO YES YES YES X X 22/06/04 11.45 4.5Hazelgrove Court Nursing HomePage 12 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Care homes for older people have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Hazelgrove Court Nursing HomePage 13 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · · 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.Standard 1 (1.1 ­ 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities, and terms and conditions of the home; and provides a service users guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the homes service users guide. Range of fees charged From (£) X To (£) XAny charges for extrasYES Standard met? 0If yes, please state what the extras are: Key findings/Evidence This standard was not assessed on this occasion.Hazelgrove Court Nursing HomePage 14 Standard 2 (2.1 ­ 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion.Standard 3 (3.1 ­ 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 3 Key findings/Evidence Standard met? The manager carries out pre admission assessments for all service users prior to admission. External care manager assessments are sought for all service users prior to admission. The home has recently introduced new care planning documentation that includes a comprehensive pre admission assessment.Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 2 Key findings/Evidence Standard met? Pre admission assessments and care planning within the service users files showed that needs had been assessed Staff interviewed were able to demonstrate a range of skills and knowledge that would enable them to meet the service users needs, however concerns were raised that the number and type of hoist and slings available were not sufficient to meet individual service users needs. The manager told the inspector that this issue had been raised at the recent management review and the home was awaiting appropriate assessment prior to purchase of equipment. Standard 5 (5.1 ­ 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 3 Key findings/Evidence Standard met? The manager said that all service users or representatives are encouraged to view the home prior to admission. Admissions are planned and all admissions are on a trial basis until an initial review is carried out.Hazelgrove Court Nursing HomePage 15 Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff, to deliver short term intensive rehabilitation and enable service users to return home. 9 Key findings/Evidence Standard met? The home does not offer intermediate care.Hazelgrove Court Nursing HomePage 16 Health and Personal CareThe intended outcomes for the following set of standards are: · · · · · The service users health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. Service users, where appropriate, are responsible for their own medication, and are protected by the homes 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.Standard 7 (7.1 ­ 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 3 Key findings/Evidence Standard met? Four service users files were examined. These contained plans of care and reviews. Evidence was found to show service users and/ or their representatives had been consulted and agreed to the plans of care. Service users files seen contained life histories and information on service users preferences. New care planning documentation has recently been introduced which include all areas of care planning and risk assessment. Service users families who spoke to the inspector were able to confirm that care needs are discussed with them. Standard 8 (8.1 ­ 8.13) The registered person promotes and maintains service users health and ensures access to health care services to meet assessed needs. No. of incidents where service users have been taken to Accident and Emergency during last 12 months No. of service users with pressure sores at time of inspection (from information taken from care notes) X 03 Key findings/Evidence Standard met? Service users have access to a GP of their choice and the home enables the service users to access other health professionals. This was confirmed by family members who spoke to the inspector. Staff were able to demonstrate an awareness of residents needs and how these would be met. Records seen indicated that a chiropodist visits on a regular basis and the home has access to both dental services and opticians as required.Hazelgrove Court Nursing HomePage 17 Standard 9 (9.1 ­ 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 3 Key findings/Evidence Standard Met? The home has a blister pack system of medication. On the day of the inspection an audit of medication found no concerns with ordering, returning and administration of medication. The manager told the inspector that she has spoken to a pharmacist and sought advise regarding storage of medication as required at the previous inspection and no concerns were highlighted. Standard 10 (10.1 ­ 10.7) The arrangements for health and personal care ensure that service users privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with, and examination by, health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 3 Key findings/Evidence Standard met? Staff demonstrated through observed actions and responses that they ensure the service users privacy, dignity and choice in all aspects of daily living.Standard 11 (11.1 ­ 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion.Hazelgrove Court Nursing HomePage 18 Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: · · · · 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.Standard 12 (12.1 ­ 12.4) The routines of daily living and activities made available are flexible and varied to suit service users expectations, preferences and capacities. 3 Key findings/Evidence Standard met? Staff were able to demonstrate through responses and observation of their actions that they ensures service users were given the opportunity to make choices. Service users and families who spoke to the inspector confirmed this. The home has employed an activities co-ordinator who is developing a programme of activities to meet service users needs.Standard 13 (13.1 ­ 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users preferences. 3 Key findings/Evidence Standard met? Staff told the inspector that contact with family and friends was encouraged and there was a good rapport with visitors. This was confirmed by service users and family who told the inspector that staff were always friendly and welcoming.Standard 14 (14.1 ­ 14.5) The registered person conducts the home so as to maximise service users capacity to exercise personal autonomy and choice. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion.Hazelgrove Court Nursing HomePage 19 Standard 15 (15.1 ­ 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet, which is suited to individual, assessed and recorded requirements, and that meals are taken in a congenial setting and at flexible times. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion, however service users and families who spoke to the inspector expressed their satisfaction with the quality and choice of meals.Hazelgrove Court Nursing HomePage 20 Complaints and ProtectionThe intended outcomes for the following set of standards are: · · · 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.Standard 16 (16.1 ­ 16.4) The registered person ensures that there is a simple, clear and accessible complaints procedure which includes the stages and time-scales for the process, and that complaints are dealt with promptly and effectively. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI 0 0 0 0 0 1100 Percentage of complaints responded to within 28 days . 3 Key findings/Evidence Standard met? A policy and procedure on complaints is in place. The complaints book was evidenced. This contained details of the complaint, the outcome and the complainants satisfaction.Standard 17 (17.1 ­ 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion.Hazelgrove Court Nursing HomePage 21 Standard 18 (18.1 ­ 18.6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists NO 02 Key findings/Evidence Standard met? On the day of the inspection a policy on reporting concerns with regard to the `no secrets` guidance was not available, however the training file contained information with regard to what was abuse. The home has a policy on whistle blowing. Staff who spoke to the inspector were aware of the action they must take to report any concerns.Hazelgrove Court Nursing HomePage 22 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · · 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.Standard 19 (19.1 ­ 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 3 Key findings/Evidence Standard met? The home employs a full time maintenance person to carry out routine maintenance and minor repairs. On the day of the inspection the home was found to be pleasantly decorated, clean and generally odour free. Relevant maintenance documentation was evident. All appropriate areas of the home are accessible to service users. The grounds were found to be well kept and accessible. Standard 20. (20.1 ­ 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 3 Key findings/Evidence Standard met? The home provides a range of lounges and a dining room on each floor providing accommodation to service users. These were found to be light and airy. Furnishings are domestic in character. The lighting in the communal areas is sufficiently bright and is appropriately placed.Hazelgrove Court Nursing HomePage 23 Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 3 Key findings/Evidence Standard met? Toilets and bathrooms are situated close to bedrooms and communal areas. All service users bedrooms have en suite facilities. There are separate sluice facilities.Standard 22 (22.1 ­ 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons, including a qualified occupational therapist, with specialist knowledge of the client groups catered for, and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 3 Key findings/Evidence Standard met? All areas of the home are accessible to service users. Grab rails and alarm call facilities are in place throughout the home. Specialist equipment such as hoists and pressure relieving mattress are available. The home has recently purchased a number of specialised beds.Hazelgrove Court Nursing HomePage 24 Standard 23 (23.1 ­ 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite YES NO NO 48 48 0 0 48 00 0 0 03 Key findings/Evidence Standard met? Service users rooms meet the required standard and are arranged to meet the service users needs.Hazelgrove Court Nursing HomePage 25 Standard 24 (24.1 ­ 24.8) The home provides private accommodation for each service user which is furnished and equipped to assure comfort and privacy, and meets the assessed needs of the service user. 3 Key findings/Evidence Standard met? Service users bedrooms are arranged to meet individual needs and choices. Furnishings provided are suitable to need.Standard 25 (25.1 ­ 25 8) The heating, lighting, water supply and ventilation of service users accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 2 Key findings/Evidence Standard met? All rooms are centrally heated and individual radiators can be adjusted to meet service users needs. All radiators are guarded. Lighting in service users rooms is adequate and domestic in character. Emergency lighting is provided throughout the home. Hot water temperatures records seen on the day of the inspection indicate that they continue to be checked and recorded on a monthly basis. It is recommended that the hot water temperatures in baths and showers are checked and recorded on a weekly basis, as highlighted at the previous occasion. The home has a policy on bathing service users which states that the temperatures of all baths is to be checked prior to use, however it was found that no thermometers were available in the first floor bathrooms. These should be provided to enable the staff to comply with the homes policy as recommended at the previous inspection. Standard 26 (26.1 ­ 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation and published professional guidance. 2 Key findings/Evidence Standard met? There is a policy in place for infection control and for the handling of clinical waste. Hand washing facilities are available throughout the home at appropriate locations. On the day of the inspection the home was found to be clean and generally odour free, however a number of service users were found to have an unpleasant odour. The manager told the inspector that a number of carpets are cleaned on a daily basis and the home is trying new cleaning products. She also said that a number of carpets are to be replaced in the near future.Hazelgrove Court Nursing HomePage 26 StaffingThe intended outcomes for the following set of standards are: · · · · 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 homes recruitment policy and practices. Staff are trained and competent to do their jobs.Standard 27 (27.1 ­ 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High No. staff hours X X X needs allocated No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff X X X No. staff hours allocated No. staff hours allocated No. of staff hours provided X X X X X XX X X2 Key findings/Evidence Standard met? On the day of the inspection it was found that the home was not meeting the required minimum levels of staffing. A record of staff rota was evidenced, this indicated that the home had failed to meet the minimum staffing requirements on previous occasions. An immediate requirement notice was issued. The home must meet the minimum staffing levels as required in the section 31 staffing notice agreed with the previous regulatory authority.Hazelgrove Court Nursing HomePage 27 Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of the care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 Key findings/Evidence This standard was not assessed on this occasion. 20 58 Standard met? 0Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion.Standard 30 (30.1 ­ 30.4) The registered person ensures that there is a staff training and development programme which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion.Hazelgrove Court Nursing HomePage 28 Management and AdministrationThe intended outcomes for the following set of standards are: · · · · · · · · 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 homes record keeping policies and procedures. The health, safety and welfare of service users and staff are promoted and protected.Standard 31 (31.1 ­ 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 2 Key findings/Evidence Standard met? The registered manager has the required nursing qualification and has the required experience in a management post, however she needs to gain NVQ level 4 or equivalent in management and appropriate dementia care certificate as agreed at her registration.Standard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion.Standard 33 (33.1 ­ 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion.Hazelgrove Court Nursing HomePage 29 Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure there is effective and efficient management of the business. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion.Standard 35 (35.1 ­ 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders Key findings/Evidence This standard was not assessed on this occasion. Standard met? 0 X X XStandard 36 (36.1 ­ 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion, however staff who spoke to the inspector told her that supervision continued to be carried out on an informal basis.Hazelgrove Court Nursing HomePage 30 Standard 37 (37.1 ­ 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion.Standard 38 (38.1 ­ 38.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 3 Key findings/Evidence Standard met? Policies and procedures were in place relating to health and safety. Staff stated that training relating to health and safety takes place. Records seen indicated that maintenance was carried out as required. Accidents are recorded and a monthly audit is carried out.Hazelgrove Court Nursing HomePage 31 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition Compliance The manager should attain a relevant management qualification by 2005. CommentsNONO Condition Compliance The manager to attain caring for people with dementia course or equivalent within 1 year of registration. CommentsCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Regulation Manager DateJane Bassett Ken Pollard 27 July 2004Signature Signature SignatureHazelgrove Court Nursing HomePage 32 Public reports It should be noted that all CSCI inspection reports are public documents.Hazelgrove Court Nursing HomePage 33 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 22 June 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possible Providers action plan is available at the Area Office, where this has been submitted.Hazelgrove Court Nursing HomePage 34 Action taken by the CSCI in response to provider comments: Amendments to the report were necessary NOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateNONONONote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by 28 July 2004, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESNONOOther: enter details here Hazelgrove Court Nursing HomePage 35 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I of Hazelgrove Court Nursing Home confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I of Hazelgrove Court Nursing Home am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Hazelgrove Court Nursing HomePage 36 - 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. 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