Inspection on 18/04/07 for Hazelhurst

This inspection was carried out on 18th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 no outstanding requirements from the previous inspection report, but made 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hazelhurst 20/08/08

Hazelhurst 24/08/07

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Hazelhurst 1 Broncksea Road Filton Park South Glos BS7 0SE Lead Inspector Odette Coveney Key Unannounced Inspection 18th April 2007 09:30 Hazelhurst DS0000068902.V334962.R01.S.doc Version 5.2 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 DS0000068902.V334962.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 Adults 18-65. 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 DS0000068902.V334962.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hazelhurst Address 1 Broncksea Road Filton Park South Glos BS7 0SE 0117 907 8815 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) Pryce-Jones (Filton) Ltd Mrs Hazel Lilian Pryce-Jones Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Hazelhurst DS0000068902.V334962.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: May accommodate up to 10 persons with learning difficulties requiring personal care only. Date of last inspection New Service Brief Description of the Service: Hazelhurst is a care home, which is registered with the Commission for Social Care Inspection, (CSCI). It provides accommodation and personal care for up to ten adults, male or female, who have a diagnosis of learning difficulties. The current maximum fee charged at the home is £675.00 per week, this is calculated based on an assessment of an individuals needs. Hazelhurst is privately owned and is the second care home of the proprietors; who also own St David’s Lodge, Fishponds. Mrs Hazel Pryce Jones took over as both the registered Provider and the Registered manager of the home in January 2007. The house is in north Bristol, close to the A38 Gloucester Road, where there are local shops, a library, a leisure centre and churches of various denominations. There is a regular bus service to Bristol centre, which is approximately 3 miles away. The home is also close to the Avon ring road, which connects to the motorway system. The home is a detached house that has been converted and renovated to comply with the Care Homes Regulations 2001 and National Minimum Standards. There are gardens to the front and to the rear of the property. There are communal areas for service users (a lounge, dining room and a sun lounge). There is no provision at the home for respite placements. Wheelchair access is via the rear of the property. A stair lift has been installed to the first floor of the house. All of the service users have a variety of activities that they choose to do during the day, such as attending day centres and college courses. Hazelhurst DS0000068902.V334962.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place over two days; the manager was present throughout the inspection. As part of this inspection a number of documents were examined including care plans, pre-admission assessments and those relating to staffing and training. Also examined were the arrangements for managing medication and recruitment and selection of staff. There was an opportunity to discuss with service users and staff their experience of living and working at Hazelhurst. What the service does well: What has improved since the last inspection? This was the home’s first inspection following the registration of the new provider/registered manager Mrs Hazel Pryce-Jones. Any previous requirements or recommendations made at the previous inspection are null and void. Mrs Pryce- Jones has made significant improvements in a relatively short period of time and has showed the commitment for further improvement in the areas identified. Hazelhurst DS0000068902.V334962.R01.S.doc Version 5.2 Page 6 What they could do better: Service users must be provided with information in the form of a service user’s guide in order that the home can give individuals full information about the facilities and services which are provided at the home including the aims, objectives and statement of purpose for the home. In order to ensure that services users are aware of their rights and also the rights and responsibilities of the service, the Registered Manager/Provider must ensure that all service users are provided with a contract outlining the terms and conditions of their placement and describing the services and facilities to be provided by the home and external agencies where required In order that service users can be confident that their assessed and changing needs and personal goals are reflected in their individual plan, the Registered Manager/Registered Provider must develop and agree with each service user an individual plan. This may include management of behaviour, with strategies. In order to demonstrate that staff have an understanding of individual’s needs and behaviours and also to ensure that individuals are being treated with dignity and respect, it is recommended consideration be given to the use of language within individual’s daily records. In order to ensure that service user’s money and personal property, which is held at the home for safekeeping, is stored securely these must be recorded. The Registered Provider must also ensure that service user’s money and property is clearly accounted for. In order to evaluate the risk factors for both service users and staff and to also try to reduce the likelihood of injury or accident, the home must ensure that areas of manual handling risk are assessed. In order to monitor and evaluate situations and ensure that appropriate action has been taken to reduce the likelihood of reoccurrence, The Commission must be informed of incidents, which affect those living at the home. In order that service users can feel their concerns or complaints are listened to and acted upon the Registered Manager/Registered Provider must ensure that a record is kept of all issues raised or complaints made by service users Service users and staff would feel more confident that appropriate action was taken should an incident occur if the home reviewed it’s protection of vulnerable adults policy in order that it is in line with the South Gloucestershire Community Care vulnerable adults policy. In order to demonstrate that the home is committed to providing a safe, well maintained and odour free environment for service users the home must Hazelhurst DS0000068902.V334962.R01.S.doc Version 5.2 Page 7 ensure that all areas of the home are odour free, that a window restrictor is fitted to an identified window and that furniture for service users use is safe. In order to demonstrate that documents at the home comply with current legislation and recognised professional standards and also to provide clear guidance and direction for staff, the home must have in place all policies and procedures as identified in appendix 2. A review of the documentation in place would ensure that accurate information is provided including an update of individual’s activity records and photographs on medication records. In order that all risks and hazards are identified including individual needs of service users and what the procedure is at night, the home’s fire risk assessment must be reviewed. 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 DS0000068902.V334962.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hazelhurst DS0000068902.V334962.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 5. Quality in this outcome area is Poor. This judgement has been made using available evidence including a visit to this service. The home has some information in place in order that individuals can make a choice about where to live, however improvement is required in this area in order that full information including the rights and responsibilities of individuals is clear. Individual’s aspirations and needs are assessed upon admission to the home. EVIDENCE: The statement of purpose was detailed and fully outlined the rights of service users and the responsibilities of the management and staff employed at the home in order that the aims of the home are met. Information contained within the statement of purpose includes the staffing arrangements. There is also information about the admissions process and whom the home is able to care for. Information within this document outlines how each person’s needs, both from a holistic and individual perspective will be met, recorded and reviewed and updated when needed. At the time of the inspection Mrs Pryce-Jones was aware that a service user’s guide for the home was needed and a requirement was made that this should be developed in order that the home can give individuals full information about the facilities and services which are provided at the home including the aims, objectives and statement of purpose for the home. Hazelhurst DS0000068902.V334962.R01.S.doc Version 5.2 Page 10 The inspector saw that the home had ‘Terms and Conditions’ in place which stated that; ‘Hazlehurst will assist me in living a fulfilled, independent life as is possible, taking my health needs into consideration and support me in having access to health professionals as and when required’. Information was given about the home’s complaints procedures, fire safety, visitors and fees. It was noted that not all of these documents had been fully completed and not all service users/and or their representatives have been given a copy of this document. The Registered Manager/Provider must ensure that all service users must be provided with this contract outlining the terms and conditions of their placement. This is to ensure that services users are aware of their rights and also that the rights and responsibilities of the service provider are outlined within a standard form of contract which provide information in respect of the accommodation to be provided, including the amount and method of payment of fees Admission to the home is through the care management approach and each admission is on a planned basis. There are presently two vacancies with no immediate plans to fill them. Mrs Pryce-Jones has a clear criteria about what needs are and are not able to be met at the home and also said that the needs and views of those already living at the home would be taken into consideration before any decision is reached. Mrs Pryce-Jones confirmed that individuals are admitted to the home for a months trial in order that a fuller picture of the services provided can be made and also in order for the home to undertake further assessment of need, this trial period would be extended if required. Hazelhurst DS0000068902.V334962.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There is limited information held at the home and individuals assessed needs, identified risks within their life, service users involvement in decision making and the consultation processes are not fully recorded. EVIDENCE: A review of four of the service user’s care files was undertaken at this inspection. The information held within these folders was incomplete and it was evident that information had been taken from these. Mrs Pryce-Jones and staff members spoken with were able to provide sound information about individual’s preferences and support needs. The Registered Manager/Registered Provider must develop and agree with each service user an individual plan, which will include the management of behaviour, with individual strategies. The care plans must describe the services and facilities to be provided by the home and external agencies where required. These plans must be completed in order that service users can be confident that their assessed and changing needs and personal goals are reflected in their individual plan. The plan must fully incorporate how individual’s needs Hazelhurst DS0000068902.V334962.R01.S.doc Version 5.2 Page 12 including social, communication, emotional, behavioural and social needs will be met and by whom. The manager and staff spoken with were able to give detailed information about the physical support, care, emotional and healthcare needs of those living at the home. Management and staff were fully conversant with individual’s changing needs and areas of their life, which are important to them and how the home can ensure that these needs are met. Mrs Pryce Jones confirmed that she had an established care planning format for recording of individuals needs. Mrs Pryce- Jones further confirmed that at this current time arrangements were in place for all individuals living at the home to have a full assessment undertaken by a care manager and this will include seeking and recording individual’s wishes and choices, establishing risk factors and social activities. The information gathered during these assessments will be incorporated into the plans developed by the home. Following a review of individual’s daily records it was noted that there was some use of inappropriate language in respect of how some staff described individuals behaviour. Therefore it is further recommended that consideration should also be given to the use of language within these records. In order to demonstrate that staff have an understanding of individual’s needs and behaviours and also to ensure that individuals are being treated with dignity and respect. A review of the care files and documentation in place would ensure that accurate information is provided including an update of individual’s activity records and photographs on medication records. It was noted that there were no assessments in place to show how individuals had been assessed in respect of the risk of falls and their transfer needs and a requirement was made that manual handling risk assessments must be completed in order to evaluate the risk factors for both service users and staff and to try to reduce the likelihood of injury or accident. These assessments would ensure that individuals are supported appropriately and safely. Mrs Pryce Jones stated that restraint is not used at this home and would only be used as a last resort and usually to ensure the safety of the other people living in the home. Decisions surrounding this would be underpinned by seeking advice and a multi-disciplinary approach. During the inspection staff were observed asking individuals for their views and opinions and they were encouraged by staff to make choices on aspects that affect their life. Individuals were observed walking around the home, and approaching staff. Residents looked reasonably relaxed and settled in their environment Hazelhurst DS0000068902.V334962.R01.S.doc Version 5.2 Page 13 Hazelhurst DS0000068902.V334962.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals are provided with information and opportunities for personal development, to engage in the community and to have appropriate relationships. EVIDENCE: Some discussion took place with Mrs Pryce-Jones in respect of the current situation in respect of day support and individual’s opportunities for personal development. Mrs Pryce-Jones said that there is a current social service review of day care services within South Gloucestershire and told of how this could potentially impact for those living at Hazelhurst. Mrs Pryce-Jones confirmed that holidays were being planned with individuals based on their preferences and these would be arranged on an individualised basis later in the year. There was evidence in place at the home to demonstrate that staff support service users to become part of, and participate in, the local community, on Hazelhurst DS0000068902.V334962.R01.S.doc Version 5.2 Page 15 both days of the inspection service users were supported to attend varied day care activities. One of the service users was celebrating their birthday and had decided to go with a staff member to a local pub for lunch, upon their return they told the inspector they had had a good time. Individuals attend church and are supported with their faith. Since Mrs Pryce-Jones took over as the Registered Provider of the home she has made contact with the relatives of those who live at the home and is keen to establish relationships with them. It was clear that service users are able to choose whom they wish to see and when and can see visitors in private in their rooms if they wish. Those living at the home are provided with a key to their own room and bathrooms are lockable in order to maintain individual’s privacy. Staff when talking about individuals used services users preferred form of address as recorded in care plan documentation. During the inspection staff were observed interacting with service users and not talking exclusively to each other. Staff members and Mrs Pryce Jones confirmed that following a GP’s advice one of the services users is now on a ’healthy eating plan’; they confirmed that individuals are offered choices and have fresh fruit and vegetables available to them. A person confirmed that they enjoyed the food and alternatives were available. Mrs Pryce Jones said that there are plans in the future to develop an area near the kitchen in order that service users can prepare themselves light snacks and drinks. The inspector looks forward to reviewing progress in this area at the next inspection. Hazelhurst DS0000068902.V334962.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported appropriately in aspects of their physical and healthcare needs. Systems of medication are good. EVIDENCE: Information seen in care records, interactions observed between staff and service users, information recorded in daily diaries and risk assessments showed that guidance and support regarding personal hygiene is given when required and at a level and pace appropriate to the service users. All service users are registered with a local GP and information seen in records confirmed that individuals are supported in other specialist areas of their heath such as anxiety support, mental health and special diets. From discussions with staff and information seen in care records it was evident that people at the home are supported to attend health appointments and records are completed after each visit. This ensures a consistent approach to meeting individual needs. The home has purchased a new trolley in which to store medication. This was found to be secure, systems of medication administration, recording and storage were found to be good. A disposal book was in place for medication Hazelhurst DS0000068902.V334962.R01.S.doc Version 5.2 Page 17 that is no longer required and medication audits were in place for medication at the home. Individuals looked as if they had chosen their own clothes, hairstyle, makeup and their appearance reflected their personality and was appropriate to their age. Hazelhurst DS0000068902.V334962.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23. Quality in this outcome area is Poor This judgement has been made using available evidence including a visit to this service. The home does not have the correct information in the form of protection of vulnerable adults polices. Records of complaints made to the home, including outcomes of any investigation must be better recorded. EVIDENCE: The Registered Manager/Registered Provider must ensure that a record is kept of all issues raised or complaints made by service users, details of any investigation, action taken and outcome; and this record should be checked at least three monthly. This must be in place in order that service users can feel their views are listened to and acted upon and that records are maintained to demonstrate that issues are dealt with and responded to in line with the home’s complaints procedure. A review of monies held for safekeeping was undertaken at this inspection and of three people’s monies checked, two records did not correspond with the money held. It was also noted that the facility where money is stored was not locked during the inspection. It was further noted that inventories of individual’s property at the home had not been fully completed. It is required that service user’s money, which is held at the home for safekeeping, is stored securely and individual’s property must be recorded and correspond with records being maintained at the home. This is in order to ensure that money and property is being audited and managed effectively in line with the organisations policies and procedures. The home has in place a copy of the South Gloucestershire protection of Vulnerable Adults policy and Mrs Pryce-Jones was aware that the safe guarding Hazelhurst DS0000068902.V334962.R01.S.doc Version 5.2 Page 19 office was currently in the process of reviewing this document. Mrs Pryce-Jones also had in place a ‘Whistle Blowing’ procedure in order that staff had the information needed should they wish to raise concerns about practices within the home without fear of reprisals. The home must review the protection of vulnerable adults policy in order that it is in line with the South Gloucestershire Community Care vulnerable adults policy. The home’s document must not contain information stating that the home or any employees at the home will undertake an investigation of any allegations made. It was noted during a review of individual’s records that there had been incidents within the home, which had affected the wellbeing of other service users. The Commission must be informed of incidents in order to monitor and evaluate situations and ensure that situations have been dealt with effectively and all risks evaluated in order to reduce the likelihood of a reoccurrence. Hazelhurst DS0000068902.V334962.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27, 28, 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides a safe and hygienic environment for the service users and staff. EVIDENCE: Since the last inspection the new proprietors have fitted a permanent wooden ramp and handrails to the front entrance into the home. The new proprietors have also installed a stair lift to the first floor and service users have benefited from this. Mrs Pryce Jones has also installed a new fire alarm system and an emergency call bell for individual’s use and vanity units in bedrooms have been replaced This demonstrates a commitment from the new provider in maintaining a good and much improved environment for service users. At this inspection a number of areas are being redecorated and improved upon and the inspector looks forwarding to reviewing progress in this area at the next inspection. Hazelhurst DS0000068902.V334962.R01.S.doc Version 5.2 Page 21 There are currently no individuals at this home who share a room; this is in line with good practice. The home employs a domestic to assist with the cleaning of the home; this person was seen to be completing their duties on both days of the inspection. During a tour of the home it was noted that a window catch was broken to bedroom window on the upper floor of the home. It is required that the home must repair the window or fit a window restrictor in order to ensure the safety of the individual accommodated in that room. It was noted that one individual’s room had an odour; Mrs Pryce-Jones was aware of this and told of efforts made to eliminate this. It was her view that the most effective method would be to remove the carpet and replace this with washable flooring. A requirement was made that the source of odour in an individual’s room must be eliminated in order that the area in which the individual lives does not smell and that the likelihood of cross contamination is reduced. It was noted on the landing of the stairs that there were boxes and documents and other ‘clutter’, this must be removed in order to ensure that this area is safe. The home has a good sized dining area and adjoining this is a ‘sun lounge’ with steps, which lead onto the garden. It was noted in this area there was a dining chair with a broken leg, it is the home’s responsibility to ensure this item of furniture is safe for use. Hazelhurst DS0000068902.V334962.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing arrangements in the home are satisfactory so that the needs of service users can be met in an efficient way with care being provided by skilled and competent staff. The recruitment and selection of staff is undertaken to make sure that as far as possible the health and welfare of individuals are protected. EVIDENCE: On the day of inspection, there was a friendly and interactive atmosphere in the home. Individual’s looked well cared for and were noted talking to staff in an informal way. Staff spoken with made complementary remarks about the manager and said they would approach her if there was any problem. Staff supervision was reviewed. Evidence from the records viewed showed that staff have received supervision. Staff spoken with confirmed that they have received supervision and that they benefited from the process. Recruitment and selection records were looked at and showed that the necessary checks are place i.e. 2 references and Criminal Records Bureau Check (CRB). Hazelhurst DS0000068902.V334962.R01.S.doc Version 5.2 Page 23 Application forms provided full and detailed information about applicants including full employment history, as required. Training records were looked at and evidenced that those inspected had undertaken the mandatory areas of training; Mrs Pryce Jones spoke of future training plans for staff to include National Vocational Qualification, Manual Handling, and basic food hygiene. Progress in these areas will be reviewed at the next inspection. Hazelhurst DS0000068902.V334962.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 40, 41, 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is leadership, guidance and direction to staff. Service users would benefit if full policies and procedures were in place and also if the homes fire risk assessment was reviewed and updated. EVIDENCE: Mrs Hazel Pryce-Jones is a director of Pryce-Jones (Filton) Ltd. Prior to her ‘fit persons interview’ Mrs Pryce-Jones completed a full and detailed registration application in relation to the purchase of the home. As part of the registration process Mrs Pryce Jones submitted a detailed personal application, a comprehensive CV and an appropriate CRB Certificate. Evidence of identity, and references confirmed her suitability. At her ‘fit person’s’ interview on 3rd January 2007 conducted by Helen Taylor the applicant demonstrated a good understanding of the role of the responsible individual in respect of the care home. Hazelhurst DS0000068902.V334962.R01.S.doc Version 5.2 Page 25 During the site visit staff spoke highly about the management style of Mrs Pryce-Jones. It was evident that she offered her staff clear direction and was motivational. Staff stated that she operates an open door policy. When Mrs Pryce Jones took over as the Registered Provider of the home there were no policies and procedures left at the home; Mrs Pryce- Jones has worked diligently in order to develop and implement as many of these documents as possible during this period of time; however it was noted that some of these were missing, those not in place included record keeping and access to files. The home must have in place those policies and procedures as identified in appendix 2 in order to demonstrate that these documents comply with current legislation and recognised professional standards and also to provide clear guidance and direction for staff. Accidents were recorded appropriately and reviewed as required. The fire log-book was noted to be up to date and evidence from records and confirmation from staff showed that staff have attended fire drills. The home has a fire risk assessment in place, however this needs further expansion and it is required that the home’s fire risk assessment must be reviewed in order that all risks and hazards are identified; including individual needs of service users and what the procedure is at night. This inspection did not focus on the financial viability of the home. There was no evidence that the financial viability of the service was threatened in any way. Hazelhurst DS0000068902.V334962.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 2 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 X 2 3 2 X Hazelhurst DS0000068902.V334962.R01.S.doc Version 5.2 Page 27 N/A Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. Standard YA24 YA30 YA5 Regulation 13(1) 4 c 13 (3) 5 (1) c Requirement Identified bedroom window to be made safe. Odour identified in service users bedroom to be eliminated. All service users must be issued with a completed contract outlining the terms and conditions of their placement. A service user’s guide must be produced in order to provide sufficient information to service users. Manual handling risk assessments must be in place for all service users. Service user’s money must be held securely, individual cash and personal property must be recorded and accounted for. Investigations into complaints must be fully documented with outcomes recorded The Commission must be notified of incidents, which affect the wellbeing of service users. The home’s Protection of Vulnerable Adults policy to be reviewed and updated where required. Care plans to be fully developed DS0000068902.V334962.R01.S.doc Timescale for action 18/05/07 18/05/07 18/06/07 4. YA1 5 18/06/07 5. 6. YA9 YA23 13(5) 16 (2) l 18/06/07 18/05/07 7. 8. 9. YA22 YA23 YA23 YA40 22 37 13(6) 18/05/07 18/04/07 18/05/07 10. YA6 15 18/07/07 Page 28 Hazelhurst Version 5.2 for all individuals at the home. 11. 12. YA40 YA42 16 23(4) Those identified required policies and procedures to be in place at the home and be available. The home’s fire risk assessment to be reviewed and updated. 18/07/07 18/06/07 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. 2. 3. 4. 5. 6. Refer to Standard YA24 YA20 YA6 YA6 YA13 YA24 Good Practice Recommendations Clear/remove clutter from the first floor landing. Photographs to be in place on medication records. Consideration must be given to the use of language in individual’s records. The home to undertake a general review of service user’s files. Activity records/schedules of individuals to be updated. Remove/repair broken chair. Hazelhurst DS0000068902.V334962.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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. 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