Inspection on 26/09/06 for Hazelgrove Court Nursing Home

This inspection was carried out on 26th September 2006.

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 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 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 26th September 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Hazelgrove Court Nursing Home DS0000000173.V312813.R01.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.V312813.R01.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 Mrs Lesley Smith 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.V312813.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. To allow the admission of up to 3 people with a Physical Disability (PD) aged 55 years plus. To allow the admission of up to 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. 28th November 2005 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 £350 to £483. Hazelgrove Court Nursing Home DS0000000173.V312813.R01.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 a pre inspection questionnaire, five relative / visitor and six service user comment cards received by CSCI. Two visits to the home, one of which was unannounced, were carried out. During the visits, which lasted a total of seven hours the inspector carried out a tour of the environment, an audit of documentation including staff records and residents files, and spoke to five residents, six relatives, four staff members, and the manager. What the service does well: What has improved since the last inspection? What they could do better: The Manager must continue to work towards achieving the management qualification. Hazelgrove Court Nursing Home DS0000000173.V312813.R01.S.doc Version 5.2 Page 6 An appropriate lock must be used on the Laundry door to restrict the access enhancing the safety of the residents. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Hazelgrove Court Nursing Home DS0000000173.V312813.R01.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.V312813.R01.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome group is Good. This judgement has been made from evidence gathered both during and before the visit to the service. Admissions to the home only take place if the service is confident staff have the skills, ability and qualifications to meet the assessed needs of the prospective resident. EVIDENCE: During the inspection the file of a residents awaiting admission was examined. This was found to contain an assessment of need carried out by staff at the home. Both the first level nurse and the manager who spoke to the inspector confirmed that under normal circumstances a qualified member of staff from the home would visit the prospective resident to gather information and ensure the prospective resident had information about the home. In cases of emergency information would be obtained from the persons care manager. Hazelgrove Court Nursing Home DS0000000173.V312813.R01.S.doc Version 5.2 Page 9 A resident and family members who spent time with the inspector told her that they had the opportunity to visit the home and discuss care needs with the manager prior to admission. The home does not offer intermediate care. Hazelgrove Court Nursing Home DS0000000173.V312813.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. Quality in this outcome group is Good. This judgement has been made from evidence gathered both during and before the visit to the service. Each resident has a plan of care, evidence indicates that this has been discussed and agreed with them or their representative. The home has appointed key workers who build up a relationship with residents on a one to one basis. EVIDENCE: Six residents files were examined, these were found to contain assessments, risk assessments, plans of care, reviews and daily recordings. The assessment documentation included information on the resident’s life history, social history, preferred activities as well as physical and mental health needs. Evidence was seen that professionals such as GP, Chiropodist, Dietician etc are contacted as necessary. Hazelgrove Court Nursing Home DS0000000173.V312813.R01.S.doc Version 5.2 Page 11 Plans of care contained evidence of discussion and agreement with either the resident or their representative. Questionnaires from residents and relatives received by CSCI contained comments such as ‘a very good service from all’ and ‘staff are very approachable and do their best to meet ones needs’. Residents who spoke to the inspector confirmed they were happy and well cared for. One spoke of ‘ the friendly staff’ another said ‘I am well looked after’. Service users had access to photographs that identified their key worker and named nurse. One resident confirmed to the inspector that they knew who their key worker was, but said there was a good relationship with all the staff. Staff who spoke to the inspector were able to demonstrate a good knowledge of the residents, their care needs and how these are met. A sample audit found no major concerns with ordering, storage, recording and disposal of medication. Staff who spoke to the inspector confirmed that medication is administered by qualified nurses. Hazelgrove Court Nursing Home DS0000000173.V312813.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, & 15. Quality in this outcome group is Good. This judgement has been made from evidence gathered both during and before the visit to the service. Family and visitors feel welcome. Staff resources are provided to allow time for activities and stimulation. The home provides meals that offer quality variety and choice. EVIDENCE: Staff who spoke to the inspector were able to describe how they promote choice and independence where possible. All spoke of respecting resident’s privacy and dignity, and the importance of treating people as individuals. Residents or their representatives who spoke to the inspector told her residents were given choice in how they spend their day, such as when they get up, when they go to bed and where they sit. Staff are polite and friendly and respect peoples choices. The home employs a part time activities co-ordinator, who has been working with the residents in both groups and individually. Residents and staff spoke of visits to the pub, dominoes, bingo, baking and visits by pets such as a rabbit. Hazelgrove Court Nursing Home DS0000000173.V312813.R01.S.doc Version 5.2 Page 13 The home has recently developed the menus provided to reflect current good practice and guidance obtained in respect of ‘menu solutions for care homes’. All who spoke to the inspector expressed satisfaction with the quality, choice and variety of meals provided. One relative who spoke to the inspector commented on the ‘good quality food’ and the variety and choice available. The lunchtime meal was observed in the ground floor dining room. The surroundings were seen to be pleasant and the meal was unrushed. Staff were available to assist the residents as required. Fresh fruit was seen to be available. Comments received in questionnaires indicated people were made to feel welcome and were happy with the meals and choice provided. Residents who spoke to the inspector said the food was ‘good and plenty of it’. Hazelgrove Court Nursing Home DS0000000173.V312813.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome group is Good. This judgement has been made from evidence gathered both during and before the visit to the service. The home has a complaints procedure that is available to all. Resident’s representatives confirmed they had a good understanding of how to make a complaint and were clear of what can be expected to happen if a complaint is made. EVIDENCE: The home has a policy on handling complaints. This is available to residents, visitors and staff. This should be developed to include contact details of those local authorities funding placements at the home. Information received in the pre inspection questionnaire indicated the home has received one complaint in the previous 12 months. Complaints records seen at the time of the inspection confirmed this. Responses in the relative questionnaires received by CSCI indicated that people had no current concerns, and are aware of how to raise any issues. Relatives who spoke to the inspector confirmed this. Hazelgrove Court Nursing Home DS0000000173.V312813.R01.S.doc Version 5.2 Page 15 Staff confirmed that they have received training in relation to prevention of abuse and were able to demonstrate through response to questions the actions they would take if a concern arose. Hazelgrove Court Nursing Home DS0000000173.V312813.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26. Quality in this outcome group is Good. This judgement has been made from evidence gathered both during and before the visit to the service. The home has a well-maintained environment, which provides aids and equipment to meet the care needs of the residents. It is a pleasant, safe place to live with rooms that meet the NMS and have en suite facilities. EVIDENCE: The home is purpose built providing single room accommodation with en suite toilet facilities. On the day of the inspection the home was found to be clean, tidy and odour free. Resident’s rooms seen by the inspector were found to be personalised with pictures, ornaments and personal possessions. Hazelgrove Court Nursing Home DS0000000173.V312813.R01.S.doc Version 5.2 Page 17 Visitors who spoke to the inspector commented on the pleasant environment. One relative told the inspector ‘ it is always clean and tidy’. One comment in the relative questionnaires received by CSCI stated the home was ‘the best we’ve been in’. During the inspection it was seen that the home was in the process of fitting door guards to a number of bedroom and other doors. These are to replace the use of wedges and comply with fire regulations. It was also seen that the laundry door had been fitted with one and had been left unattended allowing access to the area by residents. The door to the laundry should be fitted with a suitable lock that would restrict the access to staff only. Information received in the pre inspection questionnaire indicated that the home is maintained as required. Hazelgrove Court Nursing Home DS0000000173.V312813.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28,29 & 30. Quality in this outcome group is Good. This judgement has been made from evidence gathered both during and before the visit to the service. The recruitment process is robust promoting the safety and well being of residents. Staff are receiving training. Evidence indicates that staff have the appropriate skills and ability to meet the residents needs. EVIDENCE: Comments received by the inspector from residents and relatives both on the day of the inspection and within questionnaires received by CSCI indicated that there were sufficient staff to meet the needs of the residents. However it was noted that both staff and relatives commented that at times staff were very busy, slowing the response time to resident’s requests for assistance. Two relatives who spoke to the inspector commented on the positives changes in the staffing and the attitude towards the care. Comments received by the inspector included ‘ staff are always friendly and helpful’, ‘there are plenty of staff but can be rushed’ and ‘staff know how I like things done’. Hazelgrove Court Nursing Home DS0000000173.V312813.R01.S.doc Version 5.2 Page 19 Staff rotas seen on the day of the inspection indicated that first level general nurses were on duty at all times on the elderly frail unit. Qualified staff cover in the Dementia unit was either by RMN or RGN, one of whom has completed dementia awareness training. Information received by the inspector indicated that further training was to be undertaken by the other RGN covering this unit. Information seen in staff files and within the Pre Inspection Questionnaire indicated that staff have received training including prevention of abuse, fire safety, manual handling, dementia awareness and infection control. 65 of care staff have achieved NVQ level 2 or above. Staff who spoke to the inspector confirmed this. Staff confirmed that they receive supervision and appraisal. The inspector examined files of two staff recently recruited, these were found to contain the appropriate documentation. Hazelgrove Court Nursing Home DS0000000173.V312813.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, & 38. Quality in this outcome group is Good. This judgement has been made from evidence gathered both during and before the visit to the service. The manager has the required nursing qualifications and experience and is competent to run the home. She works to improve the service and provide a good quality of life for the residents. EVIDENCE: The manager of the home has the appropriate nursing qualifications and continues to work towards her management qualification. She told the inspector that she hoped to complete this in the near future. Hazelgrove Court Nursing Home DS0000000173.V312813.R01.S.doc Version 5.2 Page 21 Residents and families made positive comments about the good communication and support given by the manager. One relative spoke of the ‘ door always being open’ and ‘ staff always listen’. The manager of the home completes regular audits with regard to care planning, medication and accidents. The home submits Regulation 26 visit reports to CSCI. The home undertook a quality audit by an external agency, RDB (Research Development and Benchmarking). The report was seen to be available within the home. The home has a range of policies and procedures that should promote the wellbeing and safety of residents. The pre inspection questionnaire received by CSCI indicated that fire alarms, fire equipment, and emergency lighting are serviced and checked as required. The response also indicates that fire tests are carried out and hot water temperatures are checked as required. The manager told the inspector that the home does not hold any personal allowances for residents, all expenditure is invoiced. Hazelgrove Court Nursing Home DS0000000173.V312813.R01.S.doc Version 5.2 Page 22 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 3 8 3 9 3 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 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Hazelgrove Court Nursing Home DS0000000173.V312813.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard OP19 OP31 Regulation 13 9 Requirement A suitable lock must be fitted to the laundry door. The manager must obtain her NVQ level 4 qualification or equivalent. (Timescale 31/12/05 not met) Timescale for action 30/11/06 30/11/06 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 OP16 Good Practice Recommendations The complaints policy should be developed to include details of the authorities funding placements at the home. Hazelgrove Court Nursing Home DS0000000173.V312813.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Tees Valley Area Office 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 Hazelgrove Court Nursing Home DS0000000173.V312813.R01.S.doc Version 5.2 Page 25 - 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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