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Inspection on 28/11/05 for Hazelgrove Court Nursing Home

Also see our care home review for Hazelgrove Court Nursing Home for more information

This inspection was carried out on 28th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home provides a friendly environment where all are welcome. Communication is good. A good rapport between staff, residents and visitors was observed. One family member told the inspector that the home `stood out above the rest`. All of the residents and families spoken to were happy with their daily lives, the care that they receive and the friendly and approachable attitude of all the staff.

What has improved since the last inspection?

Evidence seen indicates that work has been carried out to develop risk assessments in relation to the use of bedrails. Plans of care seen reflected the resident`s needs identified in assessment as required at the previous inspection. Staff have undertaken specific training in relation to dementia care that should enable them to meet residents needs and promote wellbeing. One family member who spoke to the inspector said he was aware of problems with continuity and staffing in the past, however he commented on the recent training staff have undertaken and the positive effect this and the recruitment of new staff has had in the home.

What the care home could do better:

The manager must continue to work towards achieving the management qualification.

CARE HOMES FOR OLDER PEOPLE Hazelgrove Court Nursing Home Randolph Street Saltburn-by-Sea TS12 1LN Lead Inspector Jane Bassett Unannounced Inspection 28th November 2005 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Hazelgrove Court Nursing Home DS0000000173.V267933.R01.S.doc Version 5.0 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.V267933.R01.S.doc Version 5.0 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.V267933.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. To allow the admission of upto 3 people with a Physical Disability (PD) aged 55 years plus. To allow the admission of upto 3 people with Dementia aged 55 years plus. To allow the admission of one named individual who is under the age category to reside in the home. The Manager (Mrs Lesley Smith) should attain a relevant Management qualification by 2005. Manager (Mrs Lesley Smith) to attain the `Caring for people with Dementia` course or equivalent within 1 year of registration. 10th May 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. Hazelgrove Court Nursing Home DS0000000173.V267933.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. During the unannounced inspection the inspector spoke to 2 residents, 3 family members, 5 staff and the Responsible Individual. Documentation including plans of care, training records and maintenance records were examined. The home completed a pre inspection questionnaire. 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. A total of 4 hours was spent at the home What the service does well: What has improved since the last inspection? Evidence seen indicates that work has been carried out to develop risk assessments in relation to the use of bedrails. Plans of care seen reflected the resident’s needs identified in assessment as required at the previous inspection. Staff have undertaken specific training in relation to dementia care that should enable them to meet residents needs and promote wellbeing. One family member who spoke to the inspector said he was aware of problems with continuity and staffing in the past, however he commented on the recent training staff have undertaken and the positive effect this and the recruitment of new staff has had in the home. Hazelgrove Court Nursing Home DS0000000173.V267933.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Hazelgrove Court Nursing Home DS0000000173.V267933.R01.S.doc Version 5.0 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.V267933.R01.S.doc Version 5.0 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): These standards were not assessed on this occasion. EVIDENCE: Hazelgrove Court Nursing Home DS0000000173.V267933.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7&9 Residents and family were generally positive and satisfied with the care that they receive. Plans of care seen contain sufficient information that should ensure all care needs are met. Policies and procedures in relation to the handling of medication promote the safety and wellbeing of the residents. EVIDENCE: During the inspection 4 residents plans of care were examined. These were found to contain evidence of assessment, risk assessment, care planning and review. Plans of care seen reflected needs identified in the assessment, these contained review and evaluation as required at the previous inspection. Hazelgrove Court Nursing Home DS0000000173.V267933.R01.S.doc Version 5.0 Page 10 Evidence was seen that showed the home has developed risk assessment documentation in relation to the use of bedrails as required at the previous inspections. Risk assessments seen contained evidence of consultation and agreement. Residents and family members who spoke to the inspector said they were satisfied with the care received, however one family member did express concern that some issues had been missed in the past. However these were addressed when raised with the home. One family member spoke of the ‘good care’ and that their relative was ‘very comfortable’ at the home. Another family member spoke of his ‘confidence with the care’ and stated that he felt secure and comfortable to leave his relative in the care of the home. A resident who spoke to the inspector commented on the ‘ marvellous care’ and the friendly staff. An audit of medication found no concerns with regard to the ordering, storage, administration and disposal of medication. The home has a policy and procedure in relation to the handling of medication. Staff who spoke to the inspector confirmed that medication is administered by qualified nurses. Hazelgrove Court Nursing Home DS0000000173.V267933.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 The home offers a varied and nutrious diet that meets the needs and preferences of the residents. EVIDENCE: The home has a planned menu that offers choice and variety. Staff who spoke to the inspector confirmed that resident’s preferences are accommodated and alternatives to the menu are offered if required. Resident’s files seen contained evidence of nutritional assessment. Staff who spoke to the inspector all said that special diets are catered for and the involvement of a dietician is sort where necessary. Staff also stated that there were sufficient stocks of food and this was available to make snacks when catering staff were not on duty. Lunch was observed in the ground floor dining area. The tables were appropriately set and staff were available to assist where necessary. Lunch was seen to be relaxed and unrushed. One resident who spoke to the inspector said ‘the food is beautiful’. Hazelgrove Court Nursing Home DS0000000173.V267933.R01.S.doc Version 5.0 Page 12 A family member who visited the home daily told the inspector there was always a good choice of meal and a lot of the food was ‘homemade’ and the kitchen staff were ‘great’, they are always obliging. Hazelgrove Court Nursing Home DS0000000173.V267933.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed on this occasion. EVIDENCE: Hazelgrove Court Nursing Home DS0000000173.V267933.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed on this occasion. EVIDENCE: The environmental standards were not assessed on this occasion, however, it was seen that work has been carried out to refurbish the kitchen. Hazelgrove Court Nursing Home DS0000000173.V267933.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28 & 30 Staff have received appropriate training to enable them to meet the needs of the residents. EVIDENCE: Training records seen indicated that staff have completed mandatory training including manual handling, fire safety and first aid. Staff have also received training in prevention of abuse, challenging behaviour and dementia awareness. Information contained in the pre inspection questionnaire indicated that 50 of the care staff have achieved NVQ at level 2 or above. Staff told the inspector that they were encouraged and supported to attend training. One family member who spoke to the inspector said he was aware of problems with continuity and staffing in the past, however he commented on the recent training staff have undertaken and the positive effect this and the recruitment of new staff has had in the home. Hazelgrove Court Nursing Home DS0000000173.V267933.R01.S.doc Version 5.0 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 35 & 38 Evidence indicated that the home promotes residents wellbeing and is run in their best interests. EVIDENCE: The manager of the home has the appropriate nursing qualifications and continues to work towards her management qualification. Residents and families made positive comments about the staff team, good communication and support given by the manager. One family member spoke positively of the carer / resident meetings that take place. Hazelgrove Court Nursing Home DS0000000173.V267933.R01.S.doc Version 5.0 Page 17 The responsible individual told the inspector that the home does not hold any personal allowances for residents, all expenditure is invoiced. Evidence was seen that indicated that fire extinguishers, alarms, lifts and hoists are all serviced and maintained as required. Water temperatures were seen to be checked and recorded. Staff confirmed that they had undergone training in relation to health and safety, such as Fire safety, moving and handling and first aid. Hazelgrove Court Nursing Home DS0000000173.V267933.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 x X X X X X X X X STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X 3 X X 3 Hazelgrove Court Nursing Home DS0000000173.V267933.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 31 Regulation 9 Requirement The manager must obtain her NVQ level 4 qualification or by end 2005. Timescale for action 31/12/05 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. Hazelgrove Court Nursing Home DS0000000173.V267933.R01.S.doc Version 5.0 Page 20 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.V267933.R01.S.doc Version 5.0 Page 21 - 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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