Inspection on 10/02/09 for Hazelhurst

This inspection was carried out on 10th February 2009.

CSCI found this care home to be providing an Adequate service.

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

Other inspections for this house

Hazelhurst 05/08/08

Hazelhurst 29/02/08

Hazelhurst 18/07/06

Hazelhurst 15/02/06

Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

CARE HOMES FOR OLDER PEOPLE Hazelhurst 23 Kings Road Horsham West Sussex RH13 5PP Lead Inspector Sarah MacLennan Unannounced Inspection 09:00 10 February 2009 th 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 Hazelhurst DS0000065774.V374165.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. Hazelhurst DS0000065774.V374165.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hazelhurst Address 23 Kings Road Horsham West Sussex RH13 5PP 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) 01403 276333 01403 276344 hazelhurst@ashbourne.co.uk www.southerncrosshealthcare.co.uk Ashbourne (Eton) Limited Manager post vacant Care Home 38 Category(ies) of Dementia (0) registration, with number of places Hazelhurst DS0000065774.V374165.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home with nursing - (N) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Dementia (DE). The maximum number of service users to be accommodated is 38. Date of last inspection 11th November 2008 Brief Description of the Service: Hazelhurst is a registered care home that is registered to provide care for up to 38 persons aged 65 years and over with dementia. On the day of the inspection there were 26 service users. A voluntary suspension of admissions was in place following issues in relation to the safeguarding of vulnerable adults. The registered provider is Ashbourne (Eton) ltd, a subsidiary of Southern Cross Healthcare Group Plc. There is an acting manger in post responsible for the day-to-day management of the home; the responsible individual is Ms Sarah O’Mara. The home is located near to public transport links and the town is within walking distance. Currently there is a new acting manager in post who is responsible for the day-to-day running of the home. Accommodation is provided on three floors accessed by a passenger lift. There are 29 single and 5 double bedrooms and 6 offer en-suite facilities. Communal space consists of three lounge areas and one dining area. At the time of the inspection the range of fees was £558.30 to £894.65; this does not include hairdressing, toiletries and chiropody. Hazelhurst DS0000065774.V374165.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The Commission for Social Care Inspection has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This unannounced visit formed part of a ‘key’ inspection and was carried out by Sarah MacLennan, Regulation Inspector. The acting manager was present as the representative for the establishment. It was a thorough look at how well the service is doing. It took into account detailed information provided by the manager, any information that CSCI has received about the service since the last key inspection and the findings of the two random visits to the home made on 14th October 2008 and 11th November 2008. A tour of the premises took place. On the day of this visit the inspector met with some people who use the service and some on-duty staff. Some of the comments made to the inspector are quoted in this report. Observations of the interactions between staff and the people who use the service were also used to form the judgements reached in this report. The care plans of people who use the service, staff recruitment and training records, menus, health and safety check lists, activity records, policies, procedures, medication records and storage facilities were all sampled on the day of this visit. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. We would like to thank the people who use the service and staff for their time, assistance and hospitality during this visit. What the service does well: There have been significant improvements in the quality of the service provided since the appointment of the new manager; however there needs to be evidence of sustained improvement for the benefit of existing and future residents in the home. The home provides a clean and homely environment for the people who live there. Hazelhurst DS0000065774.V374165.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Hazelhurst DS0000065774.V374165.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 Hazelhurst DS0000065774.V374165.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements have been made to the pre-admission assessment process; however due to a continued voluntary suspension of admissions it was not possible to assess how this system is working in practice. EVIDENCE: At the previous key inspection, 5th August 2008, shortfalls were noted in the pre-admission assessment process. A statutory requirement notice was served and compliance was monitored by CSCI by means of a random visit to the service on 11th November 2008. At the random visit 11th November 2008 the homes new acting manger informed the inspectors that work had taken place regarding the procedure for assessing prospective service users. The acting manager will visit prospective service users and conduct a formal assessment. One of the trained nurses will Hazelhurst DS0000065774.V374165.R01.S.doc Version 5.2 Page 9 be also be present during this assessment visit as a means of staff training. The pre-admission draft care plan will then be cross-referenced to the service users care plan. A letter of acceptance will then be sent to the prospective service user and will include a copy of the assessment. At the time of this visit, 11th February 2009, the home continued to have voluntary suspension of admissions therefore it was not possible to assess how this system was working in practice, this will be monitored through CSCIs inspection process. Hazelhurst DS0000065774.V374165.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans, procedures and practices were in place to ensure the service users health care needs are met; however, some shortfalls were noted in the documentation which can place people at risk. EVIDENCE: At the previous key inspection, 5th August 2008, the care planning and practices within the home were placing the people who use the service at risk. A statutory requirement notice was served and compliance was monitored by CSCI by means of random visits to the service on 14th October 2008 and 11th November 2008. At the random visit 14th October 2008 samples of the homes medication administration records were seen including the records relating to the two people who were having their medication disguised in food or drink. Both of these people had a risk assessment in place that contained a written explanation of the need for their medication being disguised. The medication Hazelhurst DS0000065774.V374165.R01.S.doc Version 5.2 Page 11 administration was translated in the service users care plans. The care plans contained details regarding the service users behaviour; the instructions for staff included explain and return later, use diversion tactics and allow personal space. The inspector was informed by one of the trained nurses that the result of these techniques was that sometimes the service users take the medication themselves and sometimes it is given in food, we do not crush the tablets as this is not required. The medication administration records did not contain any information regarding the disguising of medication or make any reference to the care plans. The homes medication policy had been updated. The policy included the correct information regarding the disposal of medication; however the policy was still dated 06/01/06 and stated that it was issue 01. At the random visit 11th November 2008 six peoples records including their risk assessment, weight records and medication administration records were sampled during the inspection and their care plans were inspected in detail. This included the four care plans seen at the previous inspection 5th August 2008. The acting manager stated that a reorganisation of the care plans was in progress and that staff had had some training regarding the care planning paperwork. Further training was planned for the following week that would include a practical session, finishing an assessment and writing a care plan. All the service users relatives / representatives had been written to; their involvement in the care plan review process had been requested. The acting manager was planning to complete a comprehensive personal preference plan for all the people who use the service; one of the files seen contained this plan. A care plan audit was in progress and two of the six files seen contained evidence of being audited, and a further five audits were seen. The inspectors were informed that twenty of the twenty-eight files had already been audited. The care plans seen contained some behavioural guidelines for staff, three stated that staff needed to be aware of the trigger factors that lead to distressing or challenging behaviour; however there was no further information regarding what the trigger factors were. One of the service users care plan contained confusing information stating two staff assist during bath and please give shower as safer as per risk assessment. This care plan had been reviewed three times and despite the confusing information the care plan was still relevant and unchanged Another service user had recently been in hospital following several recent falls. His falls risk assessment had been updated the falls, but there had been no change to his care plan. Hazelhurst DS0000065774.V374165.R01.S.doc Version 5.2 Page 12 On arrival at the home the inspectors overheard one of the people who use the service shouting in a distressed manner. A member of staff stated that she always becomes distressed whilst having her hair done. Her care plan stated hairdresser as requested, there was no mention that this may cause her distress. Following these visits a CSCI management review meeting was held and it was decided that the action taken so far satisfies the notice requirements for care planning but further work must be undertaken to protect individuals so that they are accurate at all times and matters such as behavioural triggers are fully known and documented. During this visit, 11th February 2009, the service user care plans and files were randomly sampled; four care plans and daily statements were looked at in detail. The people who use the service had care plans, parts of which were detailed and comprehensive, with risk assessments being completed. The daily statements evidenced that aspects of the care plans were followed The food intake records for all the people who use the service were seen. The records were generally well maintained; however there were no records of service users having an evening drink or suppertime snack on Sunday 8th February 2009. The people who use the service spoken with appeared happy with the care that they received in the home. The homes medication policy, storage facilities and administration records were seen and found to be in order; however the policy was still dated 06/01/06 and stated that it was issue 01 despite this being discussed with the acting manager at the random visit on 14th October 2008. The acting manager stated at the random visit on 11th November 2008 that he was planning to complete comprehensive personal preference plans for all the people who use the service; only one of the four files seen during this visit, 10th February 2009, contained this plan. Hazelhurst DS0000065774.V374165.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Not all the people who use the service were provided with suitable activities; limiting their opportunities to exercise choice and control over their lives. EVIDENCE: At the previous key inspection, 5th August 2008, shortfalls were noted in the provision of a regular and nutritious diet to the people who use the service. A statutory requirement notice was served and compliance was monitored by CSCI by means of a random visit to the service on 14th October 2008. At the random visit 14th October 2008 the homes new acting manger informed the inspector that a great deal of work had taken place regard the food provision within the home. Higher calorie alternatives were used in cooking, for example the use of cream instead of milk in sauces. The inspector toured the communal areas of the home during the visit. Several of the service users were sitting in the lounge eating cheese and biscuits. Snacks were seen to be readily available to the people who use the service; there were bowls of fruit, plates of cakes, glasses and jugs of fruit juice on the tables. The food intake records for all the 28 people using the service were seen for the previous Hazelhurst DS0000065774.V374165.R01.S.doc Version 5.2 Page 14 week; they were well maintained and no gaps or omissions were noted. There were laminated prompt cards located throughout the lounge and hallway to remind the people who use the service to have something to eat or drink. The weight records of the four service users identified as having significant weight loss at the previous inspection were seen. The records evidenced that their weight had stabilised, two of these service users had gained weight. The medication administration records evidenced that some service users were being given nutritional supplements. Some of the people who use the service were observed to eat lunch during this visit, 11th February 2009, they appeared happy with the food provision within the home. The menu was seen and evidenced that a nutritious diet is provided, with some alternatives were available on request. No cultural diets are currently provided. The activities programme was displayed on the notice board in the lounge was seen during this visit, 11th February 2009; however the acting manager stated that the home was not currently following any specific plan of activities. The activities records were seen and it was noted that ten of the twenty-six people who use the service had not received any form of activities in 2009. One of the people who use the service did not have any record of attending any activities since June 2008. Hazelhurst DS0000065774.V374165.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who use the service no long appeared to be at risk of harm. EVIDENCE: At the previous key inspection, 5th August 2008, there were safeguarding concerns regarding the people who use the service. A statutory requirement notice was served and compliance was monitored by CSCI by means of a random visit to the service on 11th November 2008. At the random visit 11th November 2008 the inspectors were informed that all staff had now received training in the safeguarding of vulnerable adults; this was evidenced by the homes training records. The training related to how potential abuse presents in everyday work and included issues such as leaving drinks out of reach of service users and asking service users to wait whilst staff had a break. The acting manager stated that the staff were now beginning to see that there is another way of doing things and the culture within the home was changing. The staff were observed to interact readily with service users and the atmosphere within the home was lively and cheerful. Staff morale appeared high and the staff on duty appeared to enjoy their jobs. Hazelhurst DS0000065774.V374165.R01.S.doc Version 5.2 Page 16 At the time of this inspection, 11th February 2009, a voluntary suspension of admissions to the home was in place following issues in relation to the safeguarding of vulnerable adults and the home was subject to an investigation by the Local Authority Social Care Department in line with the Sussex MultiAgency Policy and Procedures for Safeguarding Vulnerable Adults. As a result of improvements seen during this inspection and following the completion of the acting managers application to become registered with the Commission it is anticipated that the home will begin to admit service users. The home had a simple and accessible complaints procedure. Details of which were displayed in the hallway. The inspector was informed that four complaints had been received since the previous inspection, three of which had been appropriately investigated and resolved, one remained on-going. Hazelhurst DS0000065774.V374165.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a clean and homely environment for the people who live there. EVIDENCE: At the previous key inspection, 5th August 2008, the home did not provide a completely clean and well-maintained environment for people who live there. A statutory requirement notice was served and compliance was monitored by CSCI by means of a random visit to the service on 11th November 2008. At the random visit, 11th November 2008, the inspectors toured areas of the home. Improvements had been made to the environment. One of the sluice rooms had been refurbished. The inspectors were informed that work was due to start the following week to convert the downstairs Hazelhurst DS0000065774.V374165.R01.S.doc Version 5.2 Page 18 bathroom that had been out of order for some time into a wet room. A quote for this was seen. Work was due to start the following week to replace fiftyfive doors that were incorrectly fitting and damaged as a result of issues picked up at the inspection 5th August 2008 and the homes recent fire inspection. The home has increased the number of domestic staff and is actively recruiting. Some of the carpets in the bedrooms had been changed to soft lino to prevent malodour. During this visit, 11th February 2009, the inspector toured areas of the home. The downstairs bathroom had been converted to a wet room and the acting manager stated that this was proving very popular with the people who use the service and the staff. The people who use the service were able to access all areas of the home. Service users were able to access upstairs via passenger lift. The décor was domestic in nature and free from offensive odours. Hazelhurst DS0000065774.V374165.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staffing arrangements in place on the day of the inspection were sufficient to meet the needs of the people who use the service. EVIDENCE: At the previous key inspection, 5th August 2008, the people who use the service were placed at risk by insufficient staffing numbers and inadequately trained staff. A statutory requirement notice was served and compliance was monitored by CSCI by means of two random visits to the service on 14th October 2008 and 11th November 2008. At the random visit, 14th October 2008, the inspector was informed that all staff had now received dementia awareness training; this was evidenced by the homes training records. Staff had not had formal training in challenging behaviour, as the new acting manager had not been able to source appropriate training that contained enough detail and fulfilled the homes requirements. The acting manager felt that providing this inadequate training would have ticked the box but failed to change the culture within the home. Therefore, he had had informal discussion and coaching with all the staff on a 1:1 basis as part of the supervision process. The acting manager was able to provide some records to corroborate this. The homes activities coordinator had been appointed as the dignity champion. The staff were observed to interact Hazelhurst DS0000065774.V374165.R01.S.doc Version 5.2 Page 20 readily with service users and the atmosphere within the home was lively and cheerful. Staff morale appeared high and the staff on duty appeared to enjoy their jobs. At the random visit, 11th November 2008, the acting manager stated that the staff were now beginning to see that there is another way of doing things and the culture within the home was changing. The staff were observed to interact readily with service users and the atmosphere within the home was lively and cheerful. Staff morale appeared high and the staff on duty appeared to enjoy their jobs. The inspectors were informed that the staff numbers within the home were more stable and the home now had sufficient staff on duty. The staffing rota evidenced this. There had been one recent incident when there were only four staff on duty, due to sickness and there were no agency staff available. The acting manager had appropriately risk assessed this staffing level and staff were instructed to concentrate on direct care and supervision of the people who use the service, leaving tasks such as bed making for a later shift with a greater number of staff. The inspectors were informed that staff had now received training in moving and handling; this was evidenced by the homes training records. The acting manager stated that three staff were now moving and handling trainers, but there were no certificates available to evidence this. During this visit, 11th February 2009, the inspector saw the staffing rota. This demonstrated that the home maintains staffing numbers of five to seven in the morning, five or six during the afternoon and evening and three at night. The acting manager and staff on duty spoken with stated that the staffing numbers and skill mix were appropriate to meet the assessed needs of the people living in the home. Three staff files were seen during the visit and found to contain the required information and documents specified in paragraphs 1 – 9 of Schedule 2 of The Care Homes Regulations 2001 (as amended by The Care Standards Act 2000(Establishments and Agencies) (Miscellaneous Amendments) Regulations 2004). The staff training records were seen, they evidenced that most staff had received training appropriate to their work; however one registered nurse had not received any fire safety training since November 2006 and had not attended a fire drill since February 2007. The acting manager stated that training would be given prior to this staff member leading a shift. The Commission has since had written confirmation from the acting manager that this has now taken place. Hazelhurst DS0000065774.V374165.R01.S.doc Version 5.2 Page 21 All interactions observed between the staff and service users were caring and respectful. Hazelhurst DS0000065774.V374165.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There have been significant improvements in the quality of the service provided since the appointment of the new manager; however there needs to be evidence of sustained improvement for the benefit of existing and future residents in the home. EVIDENCE: The acting manager has been in post since 22nd August 2008 and has submitted an application to the commission to become registered manager. At the time of this inspection the application process was on-going; however Mr James Elder-Ennis has since been approved as the Registered Manager by the Commission. During this inspection, 10th February 2009, he demonstrated a thorough knowledge and awareness of the service users needs, a sound grasp Hazelhurst DS0000065774.V374165.R01.S.doc Version 5.2 Page 23 of his managerial responsibilities, regulations and legal requirements. Service users were seen to interact readily with him. There have been significant improvements in the quality of the service provided since the appointment of the manager. All of the statutory requirements made at the previous inspection have now been met; however one new requirement has been made with regards to the provision of activities within the home. The Commission will continue to monitor the service through its inspection process to ensure that this improvement is sustained. The manager stated that various quality audit systems were in place. These included staff meetings, staff supervisions and audits of the processes within the home. These were randomly sampled and there was evidence that action was taken following identified shortfalls. Procedures were in place to safeguard the financial interests of the people who use the service. No staff members were appointees for service users. The manager was aware of the need to maintain a safe environment for service users and staff. Required policies, procedures and safety checks were in place; samples of which were seen. Staff were observed to be following appropriate health and safety practices as they went about their work. Hazelhurst DS0000065774.V374165.R01.S.doc Version 5.2 Page 24 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 2 X 3 X X 2 Hazelhurst DS0000065774.V374165.R01.S.doc Version 5.2 Page 25 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 OP12 Regulation 16 (2) (m-n) Requirement The registered person must ensure that activities are provided to meet the needs of the people who use the service. Timescale for action 10/05/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Hazelhurst DS0000065774.V374165.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Hazelhurst DS0000065774.V374165.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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