Inspection on 30/01/06 for Hazelmere House Care Home

This inspection was carried out on 30th January 2006.

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.

Other inspections for this house

Hazelmere House Care Home 10/11/08

Hazelmere House Care Home 12/12/06

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Hazelmere House Care Home 2-4 Welholme Avenue Grimsby North East Lincs DN32 0HP Lead Inspector Stephen Robertshaw Unannounced Inspection 30th January 2006 09:30 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 Hazelmere House Care Home DS0000002849.V272275.R01.S.doc Version 5.1 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.V272275.R01.S.doc Version 5.1 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 Homearch Limited Position Vacant Care Home 30 Category(ies) of Dementia (6), Old age, not falling within any registration, with number other category (24) of places Hazelmere House Care Home DS0000002849.V272275.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd November 2005 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 new manager of the home has made an application to the Commission for Social Care inspection to be recognised as the registered manager. Hazelmere House Care Home DS0000002849.V272275.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection of the home was unannounced and was on 30th January 2006. The inspection was over a seven-hour period. The service users and visitors to the home were very positive in relation to the care that is provided and the quality of the environment. The information for this report was gathered by the inspector through reading documentation held in the home, interviews with the management and staff, and through discussions with service users and visitors to the home. What the service does well: What has improved since the last inspection? The pre-admission assessments and individual care plans in the home have continued to improve in relation to the quality and content of the records Additional funding has been agreed for the staffs NVQ training. Hazelmere House Care Home DS0000002849.V272275.R01.S.doc Version 5.1 Page 6 The manager and the staff working at the home are close to meeting their NVQ requirements. The service users prescribed medication is appropriately administered and the records were up to date and accurate. 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. Hazelmere House Care Home DS0000002849.V272275.R01.S.doc Version 5.1 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 Hazelmere House Care Home DS0000002849.V272275.R01.S.doc Version 5.1 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): 1,2,3 and 4 The service users are provided with the opportunity to visit the home and meet the staff and other service users before they decide to begin a more permanent placement there. EVIDENCE: The home has a comprehensive statement of purpose and service uses guide, however these need to be updated to include the details of the current manager. All of the other required information is provided in these documents including the registration of the home, the admission process, the complaints procedure and the size of individual rooms. The inspector observed the case files for four of the service users living at the home. They all included terms and conditions of the service users individual residencies with the home and the details of how the contract could be terminated. Hazelmere House Care Home DS0000002849.V272275.R01.S.doc Version 5.1 Page 9 The pre-admission assessments of the service users had improved in the detail that was recorded by the assessor. The manager discussed with the inspector how the pre-admission assessment could be developed further. The case files all included the service users assessment of need completed by their care management teams. The inspector spoke to several visitors to the home and many of the service users. They all confirmed that the home is able to meet the assed needs of the service users. The service users stated that ‘the staff knew how to care’ for them and that there was ‘always someone’ around’ to look after their needs. Hazelmere House Care Home DS0000002849.V272275.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 11 The homes provides for the heath and personal care needs of the service users. EVIDENCE: The inspector observed the homes care plans for four of the service users. These all included details of how the individual needs should be met. The care plans are more descriptive that pervious ones seen in the home and they had all been evaluated on a minimum of a monthly basis. The care plans that were observed were all signed by either the service user, or their representative to show their agreement to them. The care plans had been developed directly form the assessed needs identified in the homes pre-admission assessments and care management assessments. Hazelmere House does not provide nursing care. However the care plans for individual service users showed where their healthcare needs were met through the support of healthcare professionals that are based in the Hazelmere House Care Home DS0000002849.V272275.R01.S.doc Version 5.1 Page 11 community, This included GP’s, dentists, chiropodists, continence and district nurses. The care plans also included the assessment of individual service users nutritional needs. The inspector observed the administration of medication to the service users. All appropriate legislation and good practice guidelines were followed throughout these procedures. The home was in receipt of certain controlled medication. All of the records for these were accurately recorded and were up to date. All of the staff that administer medication to the service users have received accredited medication training through a local training provider. Staff interviewed were aware of the need to retain medication for service users that have died for a period of seven days in case of a coroners inquest. The inspector observed the care file of a service user that had recently died at the home. The care plans had been regularly reviewed and changed in line with the service users deteriorating health. The records also showed the service users access to health care and the contact that was maintained with their families. Hazelmere House Care Home DS0000002849.V272275.R01.S.doc Version 5.1 Page 12 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): 13,14 and 15 The service users are provided with choice throughout their daily lives and social activities. EVIDENCE: The home exceeded National Minimum Standard 13. The visitors spoken to by the inspector confirmed that they are always made to feel welcome at the home and that the staff were ‘very supportive’ of the service users. The visitors also confirmed that they can visit the home at any reasonable time and that they are always offered drinks and occasionally meals when they visit to see their family and friends. The home has frequent service user/family meetings to help to maximise the service users personal autonomy and choice. Care plans identified where service users were not able to deal with their own financial affairs who was responsible to do this for them. The inspector sampled several of the service users pocket money accounts and found them all to be up to date and were accurately recorded. Access to advocacy services were advertised around the home. Hazelmere House Care Home DS0000002849.V272275.R01.S.doc Version 5.1 Page 13 The inspector ate lunch with several of the service users. The mealtime was unrushed and the meal was well presented. Staff were observed offering support to individual service users to make sure that they had their meal. The service users and visitors confirmed to the inspector that the meals provided in the home are ‘always very good’. The inspector toured the kitchen and found it to be very clean and tidy. One of the fridges in the kitchen was recording high temperatures however this had been recorded and was being looked in to by the management. There were no special diets required in the home except low fat and low sugar. Hazelmere House Care Home DS0000002849.V272275.R01.S.doc Version 5.1 Page 14 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): 16,17 and 18 The service users welfare is safeguarded in the home and there is a clear and easy to use complaints procedure. EVIDENCE: There has only been one complaint recorded at the home since the last inspection. The complaint was in relation to poor ironing standards and wrong clothes being put in individual wardrobes. The complaint was dealt with internally and an action plan was created to minimise the risk of the same problem occurring in the future. The outcome of the investigation was discussed with the complainant who accepted the homes findings and plans. The issues were raised in a residents meeting and an explanation was given on how the staff would try to make sure that the same complaint was not made again in the future. The manager confirmed that there would be an ongoing monitoring programme in relation to the service users laundry. Service users care plans showed where they had support offered to them to enable them to vote at national and local elections. Hazelmere House Care Home DS0000002849.V272275.R01.S.doc Version 5.1 Page 15 Individual care plans showed where service users had support for their financial affairs through the Court of Protection or Power of Attorney. Staff training records showed that the staff receive Protection of vulnerable adult training through the local authority. Interviews with staff showed that they had an understanding of the homes policies and procedures for the protection of vulnerable adults and how to report suspicions of abuse. Hazelmere House Care Home DS0000002849.V272275.R01.S.doc Version 5.1 Page 16 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): 19,20,21,22,23,25 and 26 The service users are provided with a homely and comfortable environment. EVIDENCE: Since the last inspection much of the home has been redecorated. The inspector observed a maintenance and redevelopment plan for the home that included the redecoration of bathrooms and several of the service users bedrooms. At the time of the inspection the downstairs corridors had been recarpeted and the areas had been repainted and were in the process of being papered. The environment is well maintained and the service users stated that they are very happy with the condition of the home and their individual rooms. The outside of outside of the home had also been repainted. The grounds of the home are tidy and well maintained. Hazelmere House Care Home DS0000002849.V272275.R01.S.doc Version 5.1 Page 17 The service users had been given the opportunity to personalise their own rooms and this was supported through the inspector’s tour of the building and being invited in to several of the service users rooms to look around. The central heating is adjustable in individual service users bedrooms and the radiators are protected with low temperature surfaces. The lighting and furniture in the communal areas of the home are domestic in character and provide a homely atmosphere. The emergency lighting at the home is regularly serviced and tested. The inspector observed the records for this. The toilet and bathrooms are well spaced around the home and are in close to the individual rooms and communal areas. Observation of the toilets and bathrooms confirmed that the staff work well to maintain hygiene at the home and have systems in place to control the spread of infection. The home does not have sluicing facilities however the washing machines are programmable to disinfection and sluicing standards. The inspector’s tour of the premises confirmed that it was very clean, hygienic and was free of any offensive smells. Service users and visitors spoken to by the inspector stated that they were ‘very happy’ with the environment that was provided. The home has not had an overall assessment of the premises to make sure that the environment can meet the needs of the service users however individual care plans identified that all of the service users have their mobility needs and risk of falls assessed to make sure that their welfare and safety is supported in the homes environment. Individual care plans also identify the service users preferences for the furniture and fittings that are provided in their rooms. Hazelmere House Care Home DS0000002849.V272275.R01.S.doc Version 5.1 Page 18 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): 27, 29 and 30 The service users are provided with staff who have the necessary skills and knowledge to meet their assessed needs. EVIDENCE: The staff training records showed that they receive all of the required mandatory training and training in relation to older people. The records are regularly updated by the manager to make sure that all of the staff’s qualifications are up to date. The staff training records showed that the staff working at the home receive in excess to the minimum requirement of three days paid training per year and they are provided with all of the statutory training, and specialist training in relation to the needs of the individual service users. The staff personnel files that were observed by the inspector supported the evidence that new staff are employed at the home following a thorough recruitment procedure that ensures the welfare and safety of the service users. This included an application, interview records, two references and appropriate POVA first and Criminal Record Bureau clearances. Staff interviews and recorded information in the home showed that new staff complete induction and foundation training that meet the requirements of the National training Organisation workforce training targets. Hazelmere House Care Home DS0000002849.V272275.R01.S.doc Version 5.1 Page 19 The manager of the home confirmed to the inspector that the staffing levels at the home are determined through the residential forum guidelines. Service users spoken to by the inspector stated that ‘there are always enough staff’ working at the home to meet their needs. The staff and management of the home are committed to the homes requirements for NVQ training. Individual staff members are provided with a copy of the General Social Care Councils code of conduct and practice. Hazelmere House Care Home DS0000002849.V272275.R01.S.doc Version 5.1 Page 20 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): 31,323,4,35,36,37 and 38 The management of the home supports the welfare and safety of the service users. EVIDENCE: An interview with the manager of the home confirmed that she has completed the Registered Managers Award and is working towards the NVQ 4 in care. She has agreed with her NVQ assessor to have this completed by 31st March 2006. The manager of the home is still waiting for a fit person interview with the Commission. The manager has a clear understanding of the needs of older people that are living in care and there are clear lines of accountability and responsibility in the home. Hazelmere House Care Home DS0000002849.V272275.R01.S.doc Version 5.1 Page 21 Interviews with staff working at the home and discussions with service users and visitors supported that the management of the home is open, positive and provides an inclusive atmosphere. The inspector observed the pocket money accounts of four service users and they were all up to date and were accurately recorded and accounted for. Individual care plans identified when service users were not responsible for their personal finances and where other people including solicitors deal with their finances for them. The staff supervision records in the home and interviews with staff indicated that the home is meeting the minimum requirements for the supervision of the staff. The records required by regulation for the protection of service users and to ensure the effective and efficient running of the business are well recorded and maintained with the exception of that the home did not have a current business and financial plan that was open for inspection that supported that the home was financially viable and to ensure that there is an effective and efficient management of the service. This is an outstanding requirement. All of the records in the home are stored in accordance with the Data Protection Act 1998 and other statutory requirements. The service and maintenance records were observed by the inspector and were all up to date. This included safety certificates for the gas and electrical systems in the home and all of the lifting and moving equipment. The fire system was well maintained and the fire fighting equipment was serviced at the regular interval. Food hygiene and the correct storage and preparation of food to avoid food poisoning was identified as being in position in the home. The extractor in the kitchen is on a three monthly plan to clean. All electrical appliances in the home are PATT tested on an annual basis. The hot water temperatures at the outlets are recorded on a regular basis. Hazelmere House Care Home DS0000002849.V272275.R01.S.doc Version 5.1 Page 22 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 2 3 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 4 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 X 3 3 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X 1 3 3 3 3 Hazelmere House Care Home DS0000002849.V272275.R01.S.doc Version 5.1 Page 23 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. Standard OP34 Regulation 25 Requirement The registered person must ensure that the home has an up to date business and financial plan that is open to inspection and supports the financial viability of the home over a twelve-month period. The original timescale for 01 January 2006 has not been met. Timescale for action 01/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP1 OP15 OP31 Good Practice Recommendations The registered person should make sure that the new managers details are available to the service users in the homes statement of purpose and service user guide. The registered person should make sure that the fridge in the kitchen has the seals respired or is replaced. The registered person should make sure that the registered manager completed the NVQ 4 in care or equivalent. Hazelmere House Care Home DS0000002849.V272275.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Hessle Area Office First Floor 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: 0845 015 0120 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 Hazelmere House Care Home DS0000002849.V272275.R01.S.doc Version 5.1 Page 25 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!