Inspection on 29/02/08 for Hazelhurst

This inspection was carried out on 29th February 2008.

CSCI found this care home to be providing an Poor 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 10/02/09

Hazelhurst 05/08/08

Hazelhurst 18/07/06

Hazelhurst 15/02/06

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

CARE HOMES FOR OLDER PEOPLE Hazelhurst 23 Kings Road Horsham West Sussex RH13 5PP Lead Inspector Gwyneth Bryant Key Unannounced Inspection 29 February 2008 07:30 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.V359355.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.V359355.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 www.southerncrosshealthcare.co.uk Ashbourne (Eton) Limited Vacant Care Home 38 Category(ies) of Dementia - over 65 years of age (38) registration, with number of places Hazelhurst DS0000065774.V359355.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th July 2006 Brief Description of the Service: Hazelhurst is a registered care home that provides personal care for up to 38 persons aged 65 years and over with dementia. The home is located near to public transport links and the town is within walking distance. Currently there is a manager in post who is responsible for the day-to-day running of the home. Not included in the fees are hairdressing, toiletries and chiropody. The most recent inspection report is displayed in the hallway 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. Hazelhurst DS0000065774.V359355.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 0 star. This means the people who use this service experience poor quality outcomes. This was an unannounced inspection and took place over six hours. The purpose of the inspection was to check compliance with the requirements made at the last inspection and inspect key standards. There were thirty-one people in residence on the day of which four were spoken with. The Manager, three staff, the cook and the administrator were also spoken with in addition to one relative contacted following the site visit. A tour of the premises was carried out and a range of documentation was viewed including care plans, personnel and medication records. Prior to the site visit the Registered Providers were asked to provide information on the service. This was provided and the information included in this report as necessary. Nine surveys from relatives were returned and comments included: relating to mums welfare and health but it is difficult to speak to the relevant person who helps mum with personal care. • Apart from the manager the staff have remained fairly constant, they all seem caring and competent. This stability and consistency of the carers is a very strong point of the home. • The atmosphere in the home is warm and friendly. The nurses/carers are kind and very competent. • Residents are treated with respect and an effort is made to make them feel really at home. • I am generally extremely happy with my mothers care. • There is always a member of staff available to give me information What the service does well: The atmosphere in the home was comfortable, homely and relaxed and staff were seen to be kind and caring towards people living in the home. People moving into Hazelhurst are encouraged to bring in their personal possessions to personalise their bedrooms and the home has an attractive and wellmaintained garden to the rear of the property, which is safe and accessible during good weather. There is an open-house policy, which welcomes visitors at all reasonable times and satisfactory arrangements are in place for dealing with complaints are ensuring that people living in the home and their relatives feel their concerns are listened to and acted upon. Hazelhurst DS0000065774.V359355.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The home would benefit from clear leadership, guidance, direction and management. As a result, there are shortfalls in care planning, meeting healthcare needs, risk assessments, handling of medication and ensuring the autonomy and dignity of people living in Hazelhurst is protected. Care plans also need to include clear direction to staff in delivering consistent care and to recognise individual preferences in respect of daily routines, meals and leisure activities. Risk assessments also need to be expanded to identify hazards and the controls to reduce risk of harm to those living in the home. An appropriate programme of activities needs to be created that is based on individuals’ preferences to ensure social and leisure needs are met. A number of health and safety shortfalls were identified in respect of fire safety, manual handling and infection control, which impinge on the safety of both staff and people living in the home. All parts of the home must be kept clean and free from offensive odours as it detracts from the general attractiveness of the home. A staff induction and development programme needs to be implemented to ensure they have the required skills to provide appropriate care. Staffing levels, need to be reviewed and be based on the needs of people living in the home, in particular for those people who are immobile or have complex care needs. All staff need to receive appropriate training in Protection of Vulnerable Adults, infection control and dementia care to ensure they have the skills to provide appropriate care to people living in Hazelhurst. Improvements need to be made to the recruitment practice to ensure people are not at risk when appropriate checks are not carried out. Quality monitoring and quality assurance systems need to be fully developed and implemented to enable the Registered Provider to objectively evaluate all aspects of the service. The use of correction fluid on care plans, recruitment and training records must cease as it is important that all records pertaining to the running of the home are clear, accurate and up to date. Please contact the provider for advice of actions taken in response to this Hazelhurst DS0000065774.V359355.R01.S.doc Version 5.2 Page 7 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.V359355.R01.S.doc Version 5.2 Page 8 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.V359355.R01.S.doc Version 5.2 Page 9 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): 3 and 4 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements need to be made to the admission assessment to demonstrate the needs of people moving into the home can be met. EVIDENCE: The pre-admission assessments for the last three people admitted to the home were viewed and while they identified needs, they did not include information as to how the home will meet those needs. There was particular concern for one person admitted two days prior to the site visit whose pre-admission assessment was very basic and a care plan had yet to be developed. There is a notice on each person bedroom door which includes the name and photograph of the occupant and who to contact with queries and these need to be updated with the name of the current manager. Intermediate care is not provided. Hazelhurst DS0000065774.V359355.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): 7, 8, 9 and 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. All aspects of service users health, welfare and care must be identified and planned for, in order to clearly direct staff in the delivery of appropriate care and improvements in the administration in medication need to be made to ensure people living in the home are not at risk. EVIDENCE: Four care plans were viewed and in the main were found to include most aspects of care needs. However, some parts were inconsistent or contradictory and this needs to be addressed to ensure staff are directed in the delivery of consistent care. In addition one care plan folder merely contained the care plan template and none of it had been completed. It is important that all care needs are identified, planned for and that staff are clearly directed in meeting care needs, particularly as a number of agency staff are used in the home. Although basic risk assessments had been carried out for those at risk of tissue breakdown or of falls, they were inadequate as they did not clearly identify the Hazelhurst DS0000065774.V359355.R01.S.doc Version 5.2 Page 11 hazards nor include sufficient detail for the management of these risks, this was the case even for those people identified as being at high risk. Risk assessments must be expanded to provide staff with clear direction on the management of the risk. Turning charts were maintained for those people who needed them as were fluid charts. Due to the high number of falls sustained by people living in the home, the manager has carried out a falls audit but this has not been extended to include action to be taken to reduce the incidence of falls. One lady who had been admitted to the home two days before the site visit had falls on each of the days she had been in the home but again there was no information as to what action staff needed to take to protect this person. Relatives spoken with said that they are not given enough notice to attend the annual care plan review and this needs to be addressed, in addition relatives should be invited to the monthly reviews to ensure they are aware of changes to care needs. One care plan indicated that an individual needed to be weighed weekly. In practice this did not happen and this needs to be addressed to ensure those people whose nutritional intake need particular monitoring are not at risk. Weight charts showed that some people had lost weight but there was no information to demonstrate a referral to a GP for nutritional supplements. Not all staff have received up to date training in the safe handling of medication and this needs to be addressed as a number of shortfalls were found in the medication administration records. These included signatures being scribbled out and replaced with a code letter which indicates that medication is signed for prior to administration. In addition this same shortfall was evident in the records for prescribed food supplements so it was not clear whether or not they had been given. The nurse administering medication during the morning was seen to follow good practice in locking the drugs cupboard when she had to leave it unattended. Medication record showed that a number of individuals have medication as required but care plans did not include information to guide staff as to the triggers for this medication. It is necessary to ensure staff are aware of when to administer such medication particularly in respect of pain relief as few people living in Hazelhurst would be able to overtly express a need for medication. It was of concern that during the tour of the premises a number of prescription creams and eyewashes were found in rooms were not for use by the occupant and the prescription labels had been torn off some tubs of cream. Each of the identified shortfalls in medication procedures put people living in Hazelhurst at risk and need to be addressed without delay. Comments in surveys included: • more updates on my mothers condition – could be useful. Hazelhurst DS0000065774.V359355.R01.S.doc Version 5.2 Page 12 • • • • (name) is sometimes without her glasses. She has lost 2 pairs since admission. She needs glasses as she still has the ability to read. I am unsure if my mother has a key worker assigned to her at present I do feel that the home does meet my mothers needs, but I can see how some greater opportunities for interaction might help all residents. Information tends to be provided when asked for. Hazelhurst DS0000065774.V359355.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): 12, 13, 14 and 15 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The lifestyle experience by people living in the home does not match their expectations, choice or preferences. Meals are satisfactory but the breakfast menu needs to be adhered to. EVIDENCE: Care plans did not include full details of preferred leisure interests and daily routines therefore it was not possible to ascertain whether or not the activities provided were based on individual preferences. An activities organiser has been employed and the activity records were viewed. It was of concern that a number of people do not do any activities and others do them only once or twice a month. The activity programme showed that while musical entertainment is provided three times a month, two are provided as part of the programme for meeting religious needs. Both the manager and administrator said that staff were told to provide activities each afternoon, this does not happen in practice. When asked if staff take people out for walks the managers’ response was that it was not safe but could not explain why. While staff were seen, in general, to treat people living in Hazelhurst with care and respect, there were some concerns. It was noted that the cleaner vacuumed the sun lounge while people were in there and watching television Hazelhurst DS0000065774.V359355.R01.S.doc Version 5.2 Page 14 and one gentleman had his belt put on back to front. The senior nurse explained it was because he had a tendency to remove it. Such practices impinge on the dignity of people and should be reviewed to ensure all people in Hazlehurst are properly dressed. One returned survey indicated that not all ladies living in the home do not always have underwear on, although, generally people living in the home were clean, tidy and their clothes were clean. Seven people were already dressed and sitting in the downstairs lounge at the start of the site visit and the senior nurse on duty explained that people are dressed when they start to wander and indicated they do not want to remain in bed. This demonstrates that there is some consideration for individual preferences and this needs to be extended to all areas of the daily lives of people living in the home. It was noted that at least five of these people spent the morning sleeping in the chairs, indicating that a review of the preferred times of rising and going to bed be recorded in individual care plans and put into practice. The chef was spoken with a showed a good understanding of the menus and how to meet the needs of those with diabetes and in general menus appeared to offer food that is nutritious and well balanced. In addition the carer who served breakfast confirmed that one person did have scrambled egg and another had a fried egg sandwich. However, it was disappointing to note that the breakfast menu stated that cereals, porridge, scrambled egg and toast were available. In practice several people living in the home were served cereals or porridge with marmalade sandwiches. There was no indication in individual care plans to show that this was their choice and the manager was unable to explain who had authorised the change to the menu. Staff spoken with pointed out that regardless of what time people got up they were not allowed to give them breakfast until 9am. The manager confirmed this was authorised by him as people tended to forget they have had breakfast. Given that some people were up and walking about by 4.30am it is of concern that they only have a hot drink for the first five hours of waking. It would be good practice to provide two smaller breakfasts rather than allow a long period between getting up and eating the first meal of the day. Assistance with eating was varied with one carer demonstrating good practice to encourage a reluctant eater but another instance found that a carer did not assist in a manner that was encouraging and in line with good practice. Returned surveys indicated that visitors were always made welcome and staff were friendly and welcoming. Comments in surveys included: • • • More social activities might help stimulate the residents, particularly musical. There is always a member of staff available to given me information relating to mums welfare and health but it is difficult to speak to the relevant person who helps mum with personal care. A bit more help with suitable clothing to buy etc would be useful. DS0000065774.V359355.R01.S.doc Version 5.2 Page 15 Hazelhurst • • • • • • • I am sometimes not happy about the way mum is dressed (lack of underwear etc) but it is difficult to ascertain who is the correct person to speak to. Residents are treated with respect and an effort is made to make them feel really at home. Needs more stimulus in the lounge upstairs They are welcoming and friendly, that is all staff not just carers and they try to create a calm environment where residents are helped when needed. The menu is very good and food cooked and presented well, and reluctant eaters are encouraged to try a little. We are always welcomed whenever we visit and we never feel we have called at an awkward time. The home should provide more activities for the residents. Some of the more mentally able residents get bored. Hazelhurst DS0000065774.V359355.R01.S.doc Version 5.2 Page 16 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): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is a satisfactory complaints procedure but improvements need to be made to ensure staff are familiar with current adult protection systems. EVIDENCE: Information provided prior to the site visit confirmed that the service has policies and procedures on both complaints and Protection of Vulnerable Adults. The complaints book showed that the last complaint was dealt with and the manager explained that the correspondence would have been sent from the Head Office. This needs to be addressed to ensure all complaints records include actions taken and outcomes. The CSCI has been notified of two adult protection alerts both of which raised concerns about the number of falls sustained by people living in Hazelhurst, in particular one person who was deemed to be immobile. The outcome was that there were shortfalls in the care plans systems as staff were not directed in how to reduce risks. To date only the manager and one other member of staff have received up to date training in the Protection of Vulnerable Adults and some staff have never received this training. It is important to ensure all staff are familiar with both what is considered abusive and what action to take in the event of an allegation. Hazelhurst DS0000065774.V359355.R01.S.doc Version 5.2 Page 17 One care plan stated that due to the level of challenging behaviour the person concerned should be kept in their room. The manager said that this does not happen in practice therefore the care plan is not accurate and this needs to be addressed to ensure no one is inappropriately restrained. Comments in surveys included: • I am unsure who to approach if I have a concern but I have received a sympathetic response to concerns that I have raised. Hazelhurst DS0000065774.V359355.R01.S.doc Version 5.2 Page 18 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): 19 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Most parts of the home are maintained providing a homely and comfortable environment for people living in the home; improvements need to be made in respect of on-going maintenance and cleanliness to ensure all areas of the home are pleasing and safe. EVIDENCE: A tour of the premises was carried out and a number of randomly selected bedrooms inspected. Most parts of the home are well maintained and décor is generally good, with individual bedrooms being attractively decorated and comfortable. It was disappointing to note that some areas of the home need a thorough clean, especially the bottom of rubber bath mats, the paint splatters on chairs and handrails, commodes and toilets. However, there was evidence that refurbishment is in progress and once it is complete the issue of cleanliness should improve. The hot water delivery temperatures were tested both in communal bathrooms and individual bedrooms and most were below 400. Water needs to be Hazelhurst DS0000065774.V359355.R01.S.doc Version 5.2 Page 19 delivered at temperatures that are comfortable for people to wash in but not so hot as to place them at risk, with the optimum temperature being 430. One shower room had a notice stating that water must be 400 and the manager was unable to explain why staff had been instructed to shower people at such a low water temperature. Two bedrooms and the lift were malodorous and this needs to be addressed as the issue of odours was raised in a number of the returned surveys. Staff were seen to be working in ways that increase the risk of cross infection, such as wearing aprons in communal areas after delivering personal care and placing used gloves in the office waste bin. This needs to be addressed given that one person in the home has been identified as an active carrier of MRSA. Insufficient space to accommodate 38 people in the dining areas so some have no choice other than sit in armchairs to eat, but there is no information in care plans to show whether or not people have been given a choice over where they have their meals. Comments in surveys included: • • To do more to diminish the odour of urine – particularly in the lift The atmosphere in the home is warm and friendly. The nurses/carers are kind and very competent. The place is kept very clean and the food looks appetising. Hazelhurst DS0000065774.V359355.R01.S.doc Version 5.2 Page 20 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): 27, 28, 29 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The number of staff deployed is not sufficient to meet the needs of service users and staff training needs to be improved to ensure they have the skills to meet service users needs. Recruitment practices are not robust and do not provide safeguards to protect service users. EVIDENCE: There are 5 care assistants and 2 trained nurse on the morning shift and 5 carers and 1 trained nurse on duty during the afternoon. Night staffing consists of 1 trained nurse and 3 care assistants. The manager and administrator are supernumerary to other staff. Discussion with the manager found that staff are expected to carry out domestic tasks in addition to caring duties and agreed that there is an expectation that domestic tasks will always be completed. This suggests a task-orientated approach and good practice suggests a person centred approach ensures that the service is run in the best interests of people living in the home. This was also evident when a nurse said that one carer was required to supervise those people who are sitting in the lounge, however as the carer also had to prepare and serve breakfasts it was not possible to do so. Therefore a review of staffing levels needs to be carried out to ensure there is sufficient staff to ensure their needs are met. Additional staff may also reduce the number of falls, as people would be more closely supervised. Hazelhurst DS0000065774.V359355.R01.S.doc Version 5.2 Page 21 Only one member of staff and the manager have been trained in dementia awareness and given that the home is registered to provide care to people with dementia this is a fundamental training need for all staff. Although care plans showed that some people present challenging behaviour none of the staff have been trained to deal with this, therefore people may be at risk if inappropriate responses are applied in such a situation. The manager was unable to provide evidence of induction provided for new staff and said he didn’t think it had been done for the most recently recruited staff. Information provided prior to the site visit was inconsistent with the training matrix provided on the day. Information provided before the site visit showed that of the 16 care staff, 7 have achieved National Vocational Qualification at level 2, but the matrix supplied on the day showed that there were 18 care staff of whom only 4 had National Vocational Qualifications. A clear plan needs to be developed to ensure at least 50 of care staff have this qualification to ensure they have the skills and competence to deliver good quality care. The training matrix supplied at the time of the site visit showed that a number of other training shortfalls were evident such as pressure care, first aid, infection control, Control of Substances Hazardous to Health, health and safety, manual handling, fire safety and food hygiene each of which poses a risk factor both to staff and people living in the home. Comments in surveys included: • • • • • • • The staff at Hazelhurst have always been very kind and considerate when dealing with my mother. All the staff are happy and cheerful and the residents are well cared for, nothing ever seems too much trouble. Apart from the manager the staff have remained fairly constant, they all seem caring and competent. This stability and consistency of the carers is a very strong point of the home. The care staff are excellent and very caring, however, some of the carers speak limited English and some residents have problems understanding them, including mum. It is a great comfort to know she (mother) is in such good hands. Communication (with staff) can be a problem especially if not all are good English speakers. Since my mother arrived at Hazelhurst there have been senior staff changes. The head nurse used to talk to me proactively but I have not been approached by her replacement, however my mothers needs appear to be met adequately The care is generally good. Higher staffing levels to enable all residents to have one-to-one time. Perhaps where residents are mobile a ‘toddle and chat’ daily, outside would be possible. DS0000065774.V359355.R01.S.doc Version 5.2 Page 22 • • • Hazelhurst The recruitment documents for the last four people to be employed were viewed and while all had provided a satisfactory Protection of Vulnerable Adults and Criminal Record Bureau check, not all had provided a reference from their last employer, evidence of qualifications and a written explanation for gaps in their employment history. Discussion with manager and administrator found that there was some confusion as to who was responsible for acquiring references from past employers and this needs to be clarified to ensure people living in Hazelhurst are not at risk. Hazelhurst DS0000065774.V359355.R01.S.doc Version 5.2 Page 23 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): 31, 33, 35, 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff need to be provided with clear leadership and direction and systems need to be put in place to ensure all aspects of service users health, welfare and safety are protected and promoted. EVIDENCE: Discussion with the manager found that since the last Registered Manager left in April 2007 he has been the deputy manager until January 2008 when he became the appointed manager. He confirmed that he has a nursing qualification and is working towards gaining his Registered Managers Award. Further discussion found that the manager had a certain expectation of how care is delivered but the site visit found that his expectations are not met in practice. He agreed that he does not always have the time to have oversight of the day-to-day practice as much of his role is related to the business side of the home rather than the care element. The situation is exacerbated as Hazelhurst DS0000065774.V359355.R01.S.doc Version 5.2 Page 24 following his move from deputy manager to manager the deputy managers post has yet to be filled. This situation needs to be reviewed to ensure that consistent care is provided at all times. There were documents available confirming that audits are carried out as part of the quality monitoring system, however they lacked the follow up details to ensure that action is taken to address identified shortfalls. This is also evidenced by the high number of shortfalls identified during the site visit. The home does not manage the finances of people living in Hazelhurst, their families or solicitors do so on their behalf. Staff records showed that staff are not provided with formal one-to-one supervision and the manager said he does not provide clinical supervision for trained nurses. It is essential that all staff have regular supervision to ensure they feel supported and training needs are identified and met within acceptable timescales. Surveys were returned prior to the manager being appointed and comments in included: • • The home would benefit from the appointment of a full time manager. I feel a new manager should have been appointed by now to replace the excellent one who left in April. I think this has had a detrimental effect on communication. There were a number of shortfalls in respect of fire safety as records showed that not all staff have regular fire safety training and the manager confirmed that a fire drill has not been carried out since the last manager left. A fire safety risk assessment has been carried out but since that time a safety gate has been placed at the bottom of a flight of stairs which is also a fire exit and the manager was not sure if this presented a fire safety risk. There were letters from both the Fire Service and Environmental Health departments indicating an intention to visit but the manager was unable to locate the subsequent reports, however these documents were supplied following the site visit. Hazelhurst DS0000065774.V359355.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 2 X N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 1 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 2 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 1 X 1 Hazelhurst DS0000065774.V359355.R01.S.doc Version 5.2 Page 26 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 OP4 Regulation 14 (1) (d) Requirement Timescale for action 29/03/08 2 3. OP7 OP7 4 OP7 5. OP7 6 7 OP9 OP9 That the pre-admission document be expanded to include information as to how the home will meet assessed needs. 15 (1) That all service users have a completed care plan. 13 (4) (b) Risk assessments undertaken for (c) those at risk of falls and tissue breakdown must include the management of the risk and be regularly reviewed. 15(1) That care plans are fully and (2)(b)(c) regularly reviewed and accurately reflect service users current care needs. Sch3(o)13 Food intake records must be (4)(b)(c) maintained for all service users that require them as under Regulation 17 (1) (a) and records of action taken when service users are noted to have lost weight. 13 (2) That prescribed creams be used only for the person intended. 13(2)18 All staff who administer (1)(a)(c) medication must receive (i)(ii) satisfactory training and that all medication administration DS0000065774.V359355.R01.S.doc 29/03/08 29/03/08 29/03/08 29/03/08 29/03/08 29/03/08 Hazelhurst Version 5.2 Page 27 8 OP10 9 OP12 10 OP14 11 OP15 12 13 OP18 OP26 14 15 16 OP26 OP27 OP28 17 OP29 18 OP30 records are clear accurate and up to date. 12 (4) (a) That the home is conducted to ensure the dignity of service users is protected and promoted at all times. 16 That a planned programme of (2)(m)(n) activities based on service users interests be devised and implemented. 12 (2)(3) That service users preferred daily routines including rising and bed times are recorded and staff adhere to them at all times. 16 (2) (i) That the interval between the evening meal and breakfast is no more than 12 hours and that the breakfast menu be adhered to at all times. 13(3) That all staff be trained in adult (6)(7)(8) protection. 23(1)(d) That high standards of 16(2)(j) cleanliness are maintained (k) throughout the home, including the elimination of offensive odours. 16(2)(j) That all staff are trained in infection control and follow it in practice. 18 (1) (a) Staffing levels need to be reviewed to ensure service users needs are met. 18(1)(a) That a plan is developed to (c) (i)(ii) ensure 50 of care staff achieves NVQ level 2 and That all new staff have an induction period in accordance with the Care Skills Sector guidance. 19(4)(a-c) That all staff provide the required documentation prior to appointment, including a written explanation for gaps in the employment history, evidence of qualifications and a written reference from their last employer. 18 (1) (a) That all staff are trained in DS0000065774.V359355.R01.S.doc 29/03/08 29/05/08 29/03/08 29/03/08 29/05/08 29/03/08 29/05/08 29/05/08 29/03/08 29/03/08 29/06/08 Page 28 Hazelhurst Version 5.2 (c) (i) (ii) 19 20 21 22 OP31 OP36 OP38 OP38 17 (1) (2) (3) 18 (2) 13(5) 23 (4) (a)(b)(c) (iii) (d)(e) dementia care and Control of Substances Hazardous to Health to ensure they have the skills to deliver good care. That the use of correction fluid on documents ceases. That all staff receive regular formal supervision. That all staff have up to date training in manual handling. That fire drills are carried out regularly and records maintained and that all staff receive regular fire safety training. 29/03/08 29/03/08 29/05/08 29/03/08 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 Refer to Standard OP19 OP33 Good Practice Recommendations That hot water delivery temperatures are maintained at the optimum levels. That the quality monitoring audits include actions taken to address identified shortfalls. Hazelhurst DS0000065774.V359355.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection 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.V359355.R01.S.doc Version 5.2 Page 30 - 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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