Inspection on 07/02/06 for Hazelmere House Nursing Home

This inspection was carried out on 7th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 Nursing Home 26/06/07

Hazelmere House Nursing Home 12/10/06

Hazelmere House Nursing Home 04/07/05

Hazelmere House Nursing Home 02/03/05

Hazelmere House Nursing Home 07/07/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Hazelmere House Nursing Home Pinewood Road Summerfields Wilmslow Cheshire SK9 2RS Lead Inspector Helena Dennett Unannounced Inspection 7th February 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 Nursing Home DS0000018772.V275050.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 Nursing Home DS0000018772.V275050.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Hazelmere House Nursing Home Address Pinewood Road Summerfields Wilmslow Cheshire SK9 2RS 01625 536400 01625 536534 caldwelb@bupa.com 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) Goldsborough Limited Mrs Beryl Caldwell Care Home 50 Category(ies) of Old age, not falling within any other category registration, with number (50), Physical disability (10) of places Hazelmere House Nursing Home DS0000018772.V275050.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for a maximum of 50 service users to include: * Up to 50 service users in the category of OP ( old age not falling within any other category) * Up to 10 service users in the category of PD (physical disability), aged between55 and 65 years. The registered provider must, at all times, employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. Staffing must be provided to meet the dependency needs of the service users at all times and will comply with any guidance which may be issued through the Commission 4th July 2005 2. 3. Date of last inspection Brief Description of the Service: Hazelmere House is a two-storey care home providing nursing and personal care to residents. It was built in 1991. It is a detached, brick built property in private grounds with landscaped gardens for residents to enjoy. The home is situated in a residential area close to Wilmslow town centre. Hazelmere is a BUPA care home operated by Goldsborough Limited. The accommodation is comprised of three lounges, a conservatory, two dining rooms, 42 single and 4 double bedrooms. All the bedrooms have en-suite toilet and bathing facilities. Separate adapted bathrooms and toilets are throughout the home. Bedrooms are situated on both the ground and first floors of the home and a passenger lift is provided. A new extension is almost complete. This will provide an additional ten bedrooms with en-suite facility. Hazelmere House Nursing Home DS0000018772.V275050.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on 7th February 2006. The inspector also undertook a site visit of the new building work during the visit. A separate letter was sent to the responsible individual on the outcome of that site visit. Five residents were spoken with during the inspection and their views are included in the report. What the service does well: What has improved since the last inspection? What they could do better: Staff must ensure that all documentation kept in relation to a resident is completed in full, signed and dated. Staff must ensure that care plans are sufficiently detailed on the care needs of residents. The management of medicines needs to be improved to ensure that all residents are given their medication as prescribed. Hazelmere House Nursing Home DS0000018772.V275050.R01.S.doc Version 5.1 Page 6 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 Nursing Home DS0000018772.V275050.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 Nursing Home DS0000018772.V275050.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): Standard 3 was met at the last inspection. EVIDENCE: Hazelmere House Nursing Home DS0000018772.V275050.R01.S.doc Version 5.1 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): 7,8 & 9 Documentation relating to residents is not always completed in full, and so there is a risk that residents’ needs might not be met. Improvement is needed on the administration and recording of medicines so residents are not at risk of not being given their medication as prescribed. EVIDENCE: The residents spoken with said they were happy with the care provided at the home and felt their health needs are met. Three resident care files were examined. These contained assessments of care needs and individual care plans were in place. Risk assessments had been carried out. Hazelmere House Nursing Home DS0000018772.V275050.R01.S.doc Version 5.1 Page 10 The care plans in place generally outlined the residents’ needs and action to be taken by staff to meet those needs. Some of the plans required more detail to ensure that resident’s needs are monitored and met. For example in one resident’s care file the nutritional risk assessment identified that the resident could be at high risk. A plan of care for eating and drinking was in place. This did not mention the need to monitor the residents weight, however it did record that staff should monitor what the resident was eating and drinking. A chart was kept to record the resident’s food and fluid intake. The chart had not been completed in full. The manager told the inspector that the resident’s weight was monitored weekly, staff could not find the weight chart, however the manager said the dietician had visited the previous day to provide advice. This was not recorded in the daily records. Some signatures were missing from assessment documents so it was difficult to identify who had done the assessment. A sample of medication records was examined. In one resident’s Medicine Administration Record (MAR) sheet it was difficult to ascertain whether she had received the correct dose of medicines as two handwritten entries were made on a MAR sheet with no date of receipt recorded. Only one signature had been recorded and the dates on the MAR sheets did not correlate. On another residents MAR sheet there were missed signatures for some of the medicines. Some of the MAR sheets were photocopied which made the entries difficult to read. One resident was on Warfarin tablets. Staff said that they had taken the instructions regarding the dose to be given from the resident’s family and did not verify these with the GP. This is not good practice. See Requirements 1, 2 & Recommendation 1. Hazelmere House Nursing Home DS0000018772.V275050.R01.S.doc Version 5.1 Page 11 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,&15 Visiting can take place at any reasonable time so that residents can keep in touch with their relatives and friends. Residents can choose what they want to do so exercising control over their lives. Although residents’ meals may be nourishing there is a risk that the meals may not always be hot enough so residents may not eat them. EVIDENCE: Residents spoken with said that visitors could come and go as they please. They said that they could choose whatever they wish to do. The menus were looked at on the last inspection and found to be satisfactory. Meals were given out from the kitchenettes on each floor. During lunchtime three trays containing residents meals were placed on serving racks. On the tray were the starter, a main meal and a hot desert. A carer was observed coming back into the kitchenette and using the microwave to reheat one of the meals. This is not good practice. Hazelmere House Nursing Home DS0000018772.V275050.R01.S.doc Version 5.1 Page 12 The vegetables for the residents on a soft diet were difficult to distinguish, as both cabbage and broccoli were liquidised together giving an unappetising appearance. When questioned two of the carers could not identify what vegetables they were. Two of the residents spoke with said ‘the food is not great’. One said that the presentation of the food could be improved. They said they had recently completed a satisfaction survey. See Recommendation 2 & 3 Hazelmere House Nursing Home DS0000018772.V275050.R01.S.doc Version 5.1 Page 13 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 Information about the complaints process for the home is readily available so residents and their relatives know how to make complaints and who to make them to. EVIDENCE: There is a clear complaints procedure both on display in the entrance hall and in the service user guide, which identifies the action to be taken in the event of a complaint. Residents knew who to go to if they wished to make a complaint. The Commission for Social Care Inspection is aware of two complaints being made to the home. The company is investigating these. Hazelmere House Nursing Home DS0000018772.V275050.R01.S.doc Version 5.1 Page 14 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): 19,21 &26 The home is well maintained, safe and comfortable. The home was clean and tidy. EVIDENCE: The home is well maintained. There is a large reception area on entering the home. This is well decorated and furnished and provides a comfortable space for visitors and residents to use. A partial tour of the building took place on the day of the inspection. The toilet situated near the lounge/dining area on the ground floor was identified for visitors use. This means that should a resident require the toilet they may have to travel a considerable distance to the nearest communal toilet or their own rooms in discomfort. The manager agreed to change the use of this toilet immediately. An extension to the existing building has now finished. An application for registration has been submitted to the CSCI. This is currently being processed. A new assisted bath has been provided as part of this extension. The home was clean and tidy on the day of the inspection. Hazelmere House Nursing Home DS0000018772.V275050.R01.S.doc Version 5.1 Page 15 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 &28. There were enough staff on duty to meet the needs of the residents. Several of the care staff have NVQ qualifications or equivalent so residents know they are in safe hands. EVIDENCE: Residents were very positive about the staff in the main. Comments such as ‘ staff are very good’, excellent staff’ were met. One concern was raised which was discussed with the manager who agreed to investigate. Eight of the care staff has NVQ Level 2, two hold NVQ level 3 in care qualification. The manager discussed her intention to enable additional staff to enrol on an NVQ Level 2 programme. All staff appeared professional in their approach and good relationships existed. Hazelmere House Nursing Home DS0000018772.V275050.R01.S.doc Version 5.1 Page 16 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): 31,33 & 35 The manager of the home is registered with the Commission for Social Care Inspection. The home is run for the benefit of the residents. There is a good system in place for the management of residents’ monies. Residents’ files are now kept in a locked cupboard. EVIDENCE: The manager of the home is registered with the Commission for Social Care Inspection. The manager confirmed that resident/relatives meetings are held regularly. The manager had planned to chair a debate with some residents on the afternoon of the inspection. This had to be delayed. Hazelmere House Nursing Home DS0000018772.V275050.R01.S.doc Version 5.1 Page 17 A quality assurance system is in place that involves obtaining views from the residents. Residents said that they have been asked to complete a satisfaction survey on issues relating to the home. A system is in place to manage residents’ monies. A bank account is kept in the resident’s name. Copies of invoices are kept in the residents file and computer records are kept. The home does not handle cash for residents. Resident’s files are now kept in a locked cupboard so that only authorised persons can access them. The manager confirmed that she had sought the advice from the fire safety officer on the safety place to charge batteries. This no longer takes place in the bathroom. A fire safety inspection took place on 11th October 2005 detailing issues pertaining to fire safety. The manager confirmed that all of the issues have been dealt with. Hazelmere House Nursing Home DS0000018772.V275050.R01.S.doc Version 5.1 Page 18 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 2 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 X 3 X X X X 3 STAFFING Standard No Score 27 3 28 3 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X X Hazelmere House Nursing Home DS0000018772.V275050.R01.S.doc Version 5.1 Page 19 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 OP7 Regulation 15 Timescale for action Care plans must reflect the 30/04/06 residents needs, be accurate, up to date and signed as appropriate. The registered person must 14/02/06 make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. Requirement 2. OP9 13 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 OP7 OP15 OP15 Good Practice Recommendations Staff should read the Nursing and Midwifery Councils guidelines on records and record keeping. Staff should not reheat meals. The presentation of meals should be reviewed to ensure that residents know what is offered and that this is kept hot and appetising to encourage residents to eat. Hazelmere House Nursing Home DS0000018772.V275050.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Northwich Local Office Unit D Off Rudheath Way Gadbrook Park Northwich CW9 7LT 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 Nursing Home DS0000018772.V275050.R01.S.doc Version 5.1 Page 21 - 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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