Inspection on 10/11/08 for Hazelmere House Care Home

This inspection was carried out on 10th November 2008.

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

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

Other inspections for this house

Hazelmere House Care Home 12/12/06

Hazelmere House Care Home 30/01/06

Hazelmere House Care Home 23/11/05

Hazelmere House Care Home 30/03/05

Hazelmere House Care Home 13/10/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Hazelmere House Care Home 2-4 Welholme Avenue Grimsby North East Lincs DN32 0HP Lead Inspector Kate Emmerson Key Unannounced Inspection 10th November 2008 09:50 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 Hazelmere House Care Home DS0000002849.V374131.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. Hazelmere House Care Home DS0000002849.V374131.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hazelmere House Care Home Address 2-4 Welholme Avenue Grimsby North East Lincs DN32 0HP 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) 01472 240399 01472 362955 Homearch Limited Helen Forster Care Home 30 Category(ies) of Dementia (8), Old age, not falling within any registration, with number other category (22) of places Hazelmere House Care Home DS0000002849.V374131.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th December 2006 Brief Description of the Service: Hazelmere House is situated in a residential area of Grimsby. It is within walking distance of shops. It is also on a public transport route. The home is able to support and care for up to thirty people over the age of sixty-five, six of whom can have the category of Dementia. The home is over two floors accessed by a passenger lift. An extension was completed several years ago as part of an overall refurbishment programme that has brought the standard of accommodation up to high specifications. There are twenty-eight single rooms and one shared room, and all have the benefit of en-suite facilities. There are two assisted bathrooms and a large shower room downstairs and a further assisted bathroom upstairs. The home has two lounges and a large dining room with an extra seating area at one end. There are mature gardens to the rear of the building with a patio area and lawn. There are facilities for car parking at the front and side of the building. The current fees for services provided through the home ranges between £329 and £367 per week. All service users are expected to additionally contribute a £5 a week ‘top up fee’ for the services provided at the home. Hazelmere House Care Home DS0000002849.V374131.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means that the people who use this service experience adequate quality outcomes The site visit was unannounced and took place on 11 November 2008. A pre-inspection questionnaire had been returned to the Commission before the inspection took place. We examined records held in the home including care files, staff recruitment and training files and health and safety records. The home had been through two management changes since the last inspection and the new manger had only formally been in post for a few days prior to the inspection. She had previously been the deputy manger and had worked at the home as a senior carer prior to this so had a good knowledge of the people accommodated and their needs. She had not received any formal induction into her role and responsibilities prior to the inspection and some processes had not been fully maintained prior to her taking over the role. This has lead to requirements being imposed at this inspection. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations – but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. What the service does well: People had had an assessment of their needs completed before they were admitted in to the home to make sure that they would be looked after properly at the home although these could be more detailed. Care plans had been developed in all cases to show how care needs should be met. Visitors to the home said that they are always made to feel welcome. The people who lived in the home enjoyed the meals provided. Comments included ‘excellent and plenty of variety’, ‘the meat is very tender’ and ‘the food is good’. Hazelmere House Care Home DS0000002849.V374131.R01.S.doc Version 5.2 Page 6 Complaints were well managed and people felt comfortable raising any issues but they did not have any complaints. The home was kept clean and there were no bad smells around the home. The home was suitable to meet people’s needs however there were some issues affecting the comfort of the people living in the home. Staff were provided in sufficient numbers to meet peoples needs and staff had received training in their role. Although some refresher training had not been provided when due this was addressed immediately following the inspection. What has improved since the last inspection? What they could do better: The assessments, care plans and records of care provided could be more detailed to ensure that that all information about people’s needs and preferences for their care delivery is available. The care package should be reviewed regularly to ensure that people’s needs are able to be able to met in the home. When medication is being processed for return to the pharmacy it must still stored securely to ensure the health and safety of people living in the home and prevent misappropriation of drugs. The heating system must be repaired to ensure that it is in full working order. The manager must have induction into her role to ensure that she has the knowledge and skills of all the processes that are to be maintained. Hazelmere House Care Home DS0000002849.V374131.R01.S.doc Version 5.2 Page 7 An effective quality assurance and quality monitoring system must be implemented to ensure that the service is run in the best interests of the people living in the home. Receipts for purchases on behalf of the people living in the home must be held to ensure a full audit trail of money held in the home and people can be assured that their money is safeguarded. Staff must be provided with supervision at least six times per year to ensure staff are supported to in their role. The fire systems must be checked to ensure they are in full working order. Fire alarms to be checked at last weekly and emergency lighting to be checked at least monthly. 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. Hazelmere House Care Home DS0000002849.V374131.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 Hazelmere House Care Home DS0000002849.V374131.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s needs were assessed and recorded prior to admission to admission to the home. EVIDENCE: We examined three care files of people living at the home. The care included an assessment of people’s individual needs. These had been completed before they were admitted in to the home to make sure that their needs could be met there. The assessments were a combination of the home’s pre-admission information and care management assessments of needs where people’s care was funded through the local authority. The assessments covered aspects of the individual’s health, physical and social care needs and associated risks. One of the assessments recorded only basic Hazelmere House Care Home DS0000002849.V374131.R01.S.doc Version 5.2 Page 10 details and had not been signed by the person completing the assessment. This had resulted in a very basic care plan being developed. Although there was no evidence that this persons needs were not being met it is recommended that a comprehensive assessment is always completed to ensure that all information about peoples needs and preferences for their care delivery is available. People living in the home stated that they had been given the opportunity to visit the home before they made a decision to move there on a more permanent basis. Two of these said that they had chosen the home because they had knowledge of the service through visiting relatives that had lived in the home previously. Hazelmere does not provide intermediate care to service users. Hazelmere House Care Home DS0000002849.V374131.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although people’s individual needs were met at the home, records did not always provide a full record of the care provided. Medication was generally well managed but was not safely secured at all times. People felt their privacy and dignity was promoted. EVIDENCE: All of the care files observed included care plans describing how people’s individual needs must be met. People funded through care management or health authorities had theses care plans also included in their files. Care files demonstrated that when they had health care needs that could not be met by the homes care staff; appropriate healthcare professionals including GP’s and community nurses were consulted to support the people. Hazelmere House Care Home DS0000002849.V374131.R01.S.doc Version 5.2 Page 12 The care plans did not always record the care required. In one case a person required a specific diet due to the risk of choking whilst in practice this care was being provided the care required was not recorded in a care plan or risk assessment. In another case where a district nurse had given recommendations to minimise the risk of pressure sores this had not been recorded in the care plan and care was not being provided at the frequency recommended. The care provided was recorded daily, care plans were being evaluated monthly and there was some evidence that care plans were updated as needs changed. However these records were very basic and did not always record all issues relating to care requirements and actions taken to fully evaluate the effectiveness of the care plan. There was little evidence that the care plans had been reviewed every six months, this is required to ensure that the care needs continues to be able to be met at the home. The staff that administered prescribed medication had received accredited medication training and staff competency in this role was assessed. We observed medication being given out to people, and the staff involved followed all appropriate legislation and good working practices. The staff stated that it would be beneficial to the home for more staff to have received training in the safe handling of medication. Written information received after the inspection showed that the manager had identified additional staff that would complete the medication training. The controlled drugs held in the home were appropriately stored and stored. The medication administration records included a photograph of the person to ensure that all staff were clear whom the medication was intended for. At the end of each staff shift the senior staff from either shift sign to accept responsibility for all of the medication in the home. This made sure that there was a clear audit trail for all of the medication. During the inspection some of the medication was being processed to return to the pharmacy and had been left in office, which was unlocked. The manager was advised that medication must be stored safely at all times. Staff were knowledgeable about when to administer medication where people where prescribed medication to modify their behaviour on an as required basis. However it is recommended that care plans identify this and a clear management plan is developed in each case to support this care requirement and ensure consistency of approach in managing challenging behaviour. Observation of staff interaction with people living in the home and conversations with people living in the home evidenced that people’s privacy and dignity was promoted. They stated that they could choose how to dress and where to take their meals. They said staff knocked on the door before Hazelmere House Care Home DS0000002849.V374131.R01.S.doc Version 5.2 Page 13 entering their bedroom and ensured that privacy was maintained when they were assisted with personal care. On the tour of the building it was noted that a window in one of the bathrooms did not have adequate blinds/curtains to ensure the privacy and dignity of people using this area. Hazelmere House Care Home DS0000002849.V374131.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People were enabled to maintain and develop their personal lifestyles at the home. The people who lived in the home enjoyed the food provided at the home. EVIDENCE: People living in the home described the routines in the home as ‘very flexible’. This included the times that the people got up from bed, and the times and where they ate their meals. The home’s activity co-ordinator had had her hours increased to twenty-five hours to enable her to provide additional activities in the home. She stated she had attended training with the local authority in relation to ‘providing Meaningful Activity’. The training included special activities for individuals with dementia related problems. There was little in the way of records to evidence the activities provided in the home but the coordinator stated that there were regular outings and Hazelmere House Care Home DS0000002849.V374131.R01.S.doc Version 5.2 Page 15 involvement in an activity group out of the home. There were also some posters around the home advertising some of the forth-coming activities. People living in the home said ‘there is always something going on and activities are on the board’ and ‘there is always something to join in with’. She described how records and planning were to be improved and it is recommended that this be implemented as soon as possible. The visitors to the home said they were made to feel welcome by the staff and the management and that they were usually offered refreshments when they visit. The only religious services/access to the home is currently Roman Catholic and Church of England. There were no other faiths identified at the home at the time of the inspection. We observed the lunch being served and spoke with several of the people living in the home about the meals provided. The mealtime was relaxed and individuals were given time to eat their meals. Where people required support this assistance was provided in a manner that maintained peoples dignity. The meals were well presented and all those spoken with were very complimentary about the food. Comments included ‘excellent and plenty of variety’, ‘the meat is very tender’ and ‘the food is good’. Drinks were readily accessible in communal areas. The kitchen was well maintained and the records were kept up to date. The equipment was very clean. The cook stated that the menus as written were not being followed but these were in the process of being updated to include a choice at lunchtimes. Hazelmere House Care Home DS0000002849.V374131.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had appropriate policies and procedures to support any complaints or allegations that are received. EVIDENCE: Complaints policies and procedures were in place and were displayed in the home. The home had recorded three complaints since the last inspection and these related to issues regarding a person wishing to sit in a specific chair in the communal lounge, quality of the laundry and boundary trees. These had all been resolved and records of the complaints and investigations were maintained. People spoken with at the home said they would feel comfortable to speak to staff or the manager if they were unhappy with anything at the home but they did not have any complaints. All but one of the staff spoken with were aware of the policies and procedures and what amounted to an allegation of any abuse. All of the staff had had training in safeguarding vulnerable adults but this was due for updating. The manager stated that this would be addressed as soon as possible. At the time of the inspection there was an investigation being undertaken by the Local Authority in relation to an allegation of abuse at the home. The manager had taken appropriate action to safeguard people in the home. Hazelmere House Care Home DS0000002849.V374131.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The environment was suitable to the needs of the people living in the home however there were some issues affecting the comfort of the people living in the home. EVIDENCE: A tour of the building was undertaken. The home was clean and well maintained. The toilet and washing facilities are well spaced around the home, and were close to all of the communal areas and service users’ bedrooms. The toilets and bathrooms were all very clean and tidy and generally there were no offensive odours present in the home. The ground floor shower room and bathroom in the new wing were not very inviting spaces for the people living in Hazelmere House Care Home DS0000002849.V374131.R01.S.doc Version 5.2 Page 18 the home, as they were untidy and being used as storage. The blind in one bathroom was not working and the net curtain provided did not offer sufficient coverage to obscure the view from passers by. This does not protect people’s privacy and dignity. The laundry was well organised and the washing machines were programmable to sluicing and disinfection standards. The lighting at Hazelmere was domestic in character and the radiators had low temperature surfaces to ensure the safety of the people living in the home. In one bedroom a portable radiator was in use due to problems with the heating system. A risk assessment was in place and the room temperature was being monitored. The manager stated in other rooms where people where mobile and portable heaters would not be suitable the heaters were in place to heat the rooms prior to people retiring to bed and additional blankets had been provided. The manager was requested to inform the Commission when the work to attend to the problem had been completed. The staff confirmed that they always had supplies of gloves and aprons and that individual staff needs in this area was met where they had allergies. The staff did state that they occasionally ran out of wipes, which they used for personal care. The manager stated that these were purchased on an as required basis but that she relied on staff informing her they were low. She stated that she would review this system to ensure consistent supplies in future. Hazelmere House Care Home DS0000002849.V374131.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff were provided in sufficient numbers to meet peoples needs. Staff had received training in their role. Although some refresher training had not been provided when due this was addressed immediately following the inspection. EVIDENCE: There was no evidence that the dependency of the people accommodated was used to calculate the number of staff required on duty at the home at any time as per the residential forum guidelines. The manager stated that the head office determined the numbers of staff on duty. There had recently been a reduction in the number of staff on duty in the morning following a reduction in the numbers of people accommodated in the home. The staff felt that this had increased the pressure of work due to the numbers of people that were high dependency and required two to care for them. The staff also stated that they had to assist in the laundry and the kitchen at weekends due to a reduction of staff in these areas. The manager stated that the kitchen assistant was to be replaced as soon as satisfactory recruitment checks had been obtained. The reduction in staffing levels did not appear to have impacted on the people living in the home at the time of the inspection. Comments from people living Hazelmere House Care Home DS0000002849.V374131.R01.S.doc Version 5.2 Page 20 in the home were very positive about the staff group and included ‘excellent staff, cant do enough for you’, all the staff are really good’ and ‘always there to help you’. The manager stated that there had been no new staff employed in the home since July 2007, which was prior to the current responsible individual and manager taking up post. The staff training and personnel files for five of the staff that worked at the home were examined. All of their personnel files showed that they had been employed following equal opportunities guidelines this was also supported through interviews with the management and staff. The staff had received the security vetting appropriate to their role although in one case only one reference had been obtained rather than two and there was no recent photo of the staff on file. The manager was advised to obtain a second reference for this staff member and audit all the staff files to satisfy herself that all checks had been completed. Training records showed that new staff receive induction and foundation training that meets the requirements of the Sector Skills council workforce training targets. However in two cases this training had commenced but not been completed. One member of staff confirmed that they had had induction in to the role and had attended additional training. She confirmed that they spent some time shadowing more experienced staff. There was evidence that staff had completed a wide range of training but some required refresher training in moving and handling and fire safety. The Commission was advised in writing that this training would be completed by the end of January 2009. Hazelmere House Care Home DS0000002849.V374131.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A new manager had just come into post but had had no induction into the role. Some of the systems that had been in place at the last inspection had not been maintained. Fire safety checks had not been consistently maintained and this may have put people living in the home at risk. EVIDENCE: The acting manager had just taken up post since the previous manager had left in October 2008. She had previously been the deputy manager of the home and was working towards NVQ 3 in care and was a qualified moving and handling trainer. There was little evidence that the manager had had any induction into her role and she had received no official handover from the Hazelmere House Care Home DS0000002849.V374131.R01.S.doc Version 5.2 Page 22 previous manager. She had had little time before this inspection to find her way around the records that were held and this has resulted in some gaps at this inspection. She stated that she was well supported by the senior company managers who visited the home regularly. The staff that were interviewed and the people living in the home that were spoken to evidenced that the management of the home was open, positive and approachable. However there were some comments from staff that they did not feel that the manager always maintained staff confidentiality although they could not give any evidence of when confidentiality may have been breached. The home had a quality assurance and monitoring system although this had not been maintained since May 2008. The pocket money accounts for three of the people living in the home. All of the accounts balanced with the records held. However appropriate receipts were not always available for expenditure. There had been no formal handover of the money held when the previous manager had left and the manger was advised to audit all pocket money records with a witness. Records and discussions with staff confirmed that staff supervision had not been maintained at the frequency required to meet the standards. A written supervision and appraisal plan was provided to the Commission following the inspection. In discussion staff felt they were well supported by the current manager. All of the moving and handling equipment was well maintained and the records showed that they had been serviced on a regular basis. The gas systems for the home had been due for servicing in July 08. Fire safety in the home had not been consistently maintained. The fire alarm had not been tested weekly on a consistent basis since at least June 08. The emergency lights had not been checked monthly on a consistent basis since at least May 2008. A fire risk assessment was in place but this was due for review and the there was no action plan identified to minimise the risks of fire. The fire procedures were also due for review. Fire drills were held but there was no record of who had attended fire drills. Staff were due training updates on fire safety. The Commission received written information form the home following the inspection outlining the action plan to update fire training and for the home to have a full fire check and up dated fire risk assessment by the end of December 2008. Hazelmere House Care Home DS0000002849.V374131.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 10 11 3 X 2 X X X 2 3 STAFFING Standard No Score 27 28 29 30 2 2 X 2 3 2 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 1 X 2 1 X 2 Hazelmere House Care Home DS0000002849.V374131.R01.S.doc Version 5.2 Page 24 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 OP7 Regulation 14 Requirement The care plans must record all the care required to ensure that individual’s needs are consistently met. The care package must be formally reviewed at least six monthly to ensure that the care needs continue to be able to be met at the home. Medication must be securely stored at all times to ensure the health and safety of people living in the home and prevent misappropriation of drugs. The heating system must be in full working order. Written confirmation must be provided to the Commission that work to attend to issues has been completed. This is to ensure that the temperature of the home can be maintained at a comfortable level for the people living there. The manager must obtain a second written reference for the staff member whose checks had not been fully completed. The manager must receive full induction into her role and the DS0000002849.V374131.R01.S.doc Timescale for action 01/04/09 2 OP7 14 01/04/09 3 OP9 13 01/04/09 4 OP25 23 01/04/09 5 OP29 19 01/04/09 6 OP31 10 01/04/09 Hazelmere House Care Home Version 5.2 Page 25 7 OP33 24 8 OP35 17(2) 9 OP36 18 10 OP38 23 processes to be maintained to ensure that she is able to discharge her responsibilities fully. An effective quality assurance and quality monitoring system must be implemented to ensure that the service is run in the best interests of the people living in the home. Receipts for purchases on behalf of the people living in the home must be held to ensure a full audit trail of money held in the home and people can be assured that their money is safeguarded. Staff must be provided with supervision at least six times per year to ensure staff are supported to in their role. The fire systems must be checked to ensure they are in full working order. Fire alarms to be checked at last weekly and emergency lighting to be checked at least monthly. 01/05/09 09/04/09 01/05/09 01/04/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP3 Good Practice Recommendations Comprehensive assessments to be recorded in all cases and the assessor to sign the documents on completion. This is to ensure that all information about peoples needs and preferences for their care delivery is available. Records relating to the care provided such as daily diary records and evaluation should be more detailed to enable effective review of the care plan. Where medication is prescribed to modify behaviour on an DS0000002849.V374131.R01.S.doc Version 5.2 Page 26 2 3 OP7 OP9 Hazelmere House Care Home 4 5 6 7 OP10 OP12 OP21 OP27 as required basis care plans should identify this. A clear management plan should be developed in each case to support this care requirement and ensure consistency of approach in managing challenging behaviour. The blind in the bathrooms should be replaced to ensure that people’s privacy and dignity can be maintained. Records of the activities provided at the home should be maintained for inspection to evidence that people are receiving sufficient access to activities of their choice. The bathrooms and shower rooms should be kept clear of stored items to ensure that these are pleasant areas for the people living in the home to use. The residential forum should be used to calculate the numbers of staff duty. This is to ensure that people’s dependency levels are considered when planning staffing levels. Evidence of workings should be available for inspection. The manager should audit all the staff files to satisfy herself that all recruitment checks have been completed. Where induction training has commenced this should be completed to ensure that staff have had all the necessary training for their role. The annual training plan should identify how all the mandatory training requirements will be met in future. 8 9 10 OP29 OP30 OP30 Hazelmere House Care Home DS0000002849.V374131.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection North Eastern Region Citygate Gallogate Newcastle upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 61 61 61 Fax: 03000 61 61 71 Email: enquiries.northeastern@cqc.org.uk Web: www.cqc.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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