This inspection was carried out on 3rd October 2005.
CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.
The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.
CARE HOMES FOR OLDER PEOPLE
Hazelhurst Nursing Home Bishopswood Ross-on-wye Herefordshire HR9 5QX Lead Inspector
C Presley Unannounced Inspection 3rd October 2005 02.00p 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 Nursing Home DS0000027679.V251925.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Hazelhurst Nursing Home DS0000027679.V251925.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Hazelhurst Nursing Home Address Bishopswood Ross-on-wye Herefordshire HR9 5QX 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) 01600 890600 01600 890926 Hazelhurst Nursing Home Limited Mrs Bernice Cooper Care Home 45 Category(ies) of Dementia (45), Dementia - over 65 years of age registration, with number (45), Old age, not falling within any other of places category (45), Physical disability (45), Physical disability over 65 years of age (45), Terminally ill (45) Hazelhurst Nursing Home DS0000027679.V251925.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 3rd June 2005 Brief Description of the Service: An Edwardian country house set in extensive grounds with gardens. Hazelhurst has been modernised and extended to create a care home with nursing. It is registered to offer services for up to 45 people, and most people there are aged over 65 years. On the outskirts of the village of Bishopswood, the property is approached by a long drive and is in a peaceful rural position. Hazelhurst Nursing Home DS0000027679.V251925.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection took place during the afternoon and concentrated on the standards not inspected at the last visit. What the service does well: What has improved since the last inspection?
The requirements of the last report that were inspected during this visit have been met. The home has employed an external health and safety company to ensure the home complies with relevant health and safety legislation and residents, staff and visitors to the home are kept as safe as possible. The home is piloting a study for the Gold Standard Framework for palliative care. Staff continue to improve their knowledge of caring for the resident group in the home. Hazelhurst Nursing Home DS0000027679.V251925.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Hazelhurst Nursing Home DS0000027679.V251925.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hazelhurst Nursing Home DS0000027679.V251925.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of the standards in this section of the report were inspected during this visit. For further information on core standards inspected refer to previous report. EVIDENCE: Hazelhurst Nursing Home DS0000027679.V251925.R01.S.doc Version 5.0 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9 Medication polices and procedures in place ensure medication is dealt with safely and residents are not at risk. EVIDENCE: Medication is kept in a clinical room on the first floor and is secure. Policies and procedures are in place for receiving and disposing of medication. The administration of medication including controlled drugs is safe and follows set guidelines and controlled medication is counted daily. It was noted that four records did not have a photograph of the resident; this was being addressed before the inspector left the home. Hazelhurst Nursing Home DS0000027679.V251925.R01.S.doc Version 5.0 Page 10 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of the standards in this section of the report were inspected during this visit. For further information on core standards inspected refer to previous report. EVIDENCE: Hazelhurst Nursing Home DS0000027679.V251925.R01.S.doc Version 5.0 Page 11 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of the standards in this section of the report were inspected during this visit. For further information on core standards inspected refer to previous report. EVIDENCE: Hazelhurst Nursing Home DS0000027679.V251925.R01.S.doc Version 5.0 Page 12 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 26 All staff, to ensure residents are not placed at risk from cross infection strictly adhere to infection control policies and procedures. EVIDENCE: Infection control policies and procedures seen were appropriate for a nursing home. There is a mechanical sluice on each floor of the nursing home and foul laundry is laundered in accordance with infection control procedures. Staff are aware of the risk of cross infection and have updated training as necessary from the registered manager and trained nurses. There is a plentiful supply of disposable gloves and aprons. The home is warm and odour free. Hazelhurst Nursing Home DS0000027679.V251925.R01.S.doc Version 5.0 Page 13 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 30 Staff receive induction training which is continually assessed to ensure they care for residents within a risk framework, and their care practice does not compromise the resident in any way. EVIDENCE: All care staff have a six-week induction programme, which covers all aspects of care. Care practice is continually assessed during this period. Once the induction programme is completed and staff are deemed competent they commence their NVQ training in direct care; this training is accessed externally. Hazelhurst Nursing Home DS0000027679.V251925.R01.S.doc Version 5.0 Page 14 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33 The home has a quality assurance programme which ensures all stakeholders views are taken into consideration. EVIDENCE: A recent meeting was held for residents and their families to put forward their views on the running of the home. Questionnaires and further information gained by residents and visitors will be collated into an annual quality review report. A copy of this will be available to residents and those residents and families who may be looking for a home. Hazelhurst Nursing Home DS0000027679.V251925.R01.S.doc Version 5.0 Page 15 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 x x x x x x x x 3 STAFFING Standard No Score 27 x 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x 3 x x x x x Hazelhurst Nursing Home DS0000027679.V251925.R01.S.doc Version 5.0 Page 16 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard 9 9 Regulation OP13(2) OP13(2) Requirement All medication records must contain an up to date photograph of the resident All medication when given must be signed for by the registered nurse or if omitted a code must be used Timescale for action 04/10/05 04/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Hazelhurst Nursing Home DS0000027679.V251925.R01.S.doc Version 5.0 Page 17 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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