Inspection on 06/08/07 for Hazelmere Nursing Home

This inspection was carried out on 6th August 2007.

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 Nursing Home 06/09/06

Hazelmere Nursing Home 08/11/05

Hazelmere Nursing Home 25/05/05

Hazelmere Nursing Home 17/01/05

Hazelmere Nursing Home 25/06/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Hazelmere Nursing Home 9 Warwick Road Bexhill On Sea East Sussex TN39 4HG Lead Inspector Melanie Freeman Key Unannounced Inspection 10:00 6th August 2007 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 Nursing Home DS0000013994.V345607.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 Nursing Home DS0000013994.V345607.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hazelmere Nursing Home Address 9 Warwick Road Bexhill On Sea East Sussex TN39 4HG 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) 01424-214988 01424 215118 hazelmerenh@hotmail.com Mr Rodney Gadsden Mrs Corinne Gadsden Mrs Corinne Gadsden Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23), Physical disability (23) of places Hazelmere Nursing Home DS0000013994.V345607.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. That the maximum number of service users/residents/individuals to be accommodated at any one time is twenty three (23). That the care home provides general nursing care to older people aged sixty five (65) or over on admission and can provide care to people with a physical disability. 6th September 2006 Date of last inspection Brief Description of the Service: Hazelmere Nursing Home is situated in a residential area approximately half a mile from Bexhill town centre. The main-line station, seafront and local bus services are close by. The home has a large, pleasant and well-maintained garden with an ornamental fishpond to the rear of the building. There are car parking facilities on site and unlimited parking facilities outside the Nursing Home in Warwick Road. There is a pleasant lounge overlooking the garden that is also used as a dining room. The home is registered to provide general nursing care for older people and older people with a physical disability up to a maximum of 23. Both private and socially funded service users are cared for by the home although most residents are privately funded. This home is owned and managed as a family business with Mr Gadsden being the registered owner and Mrs Gadsden being the registered manager. The home’s fees as from 01 July 2007 range between £500.00-£650.00 per person per week. Additional costs are charged for chiropody, hairdressing, newspapers, any shopping and the use of a private physiotherapist. The homes literature states that ‘We like to think that all the residents here can also feel part of that extended family. This is home where the members can live their lives in the warmth and security of the care we have to offer’. Hazelmere Nursing Home DS0000013994.V345607.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001 often use the term ‘service user’ to describe those living in care home settings. For the purpose of this report those living at Hazelmere Nursing Home will be referred to as ‘residents’. This was a key inspection that included an unannounced visit to the home and follow up contact with resident’s representatives and visiting health care professionals. Mrs Gadsden the registered manager was present throughout the inspection visit and facilitated the same. The inspection focussed on meeting and talking to residents and visitors and accessing the homes progress in meeting the requirements made at the last inspection. A tour of the premises was undertaken and a range of documentation was reviewed including the homes statement of purpose/service users guide, medication records, training records and recruitment files. In addition the care documentation pertaining to two residents were reviewed in depth. The inspector was able to eat a midday meal with the residents in the communal living area and review the arrangements for providing suitable diets. During the inspection visit five visitors were spoken to and were able to provide their views on the home and how their relatives were being cared for. Following the visit one resident’s representatives was contacted by telephone along with two health care professionals. An Annual Quality Assurance Assessment completed by the home was not received before this inspection was undertaken. What the service does well: Hazelmere Nursing Home provides a good level of nursing care to residents in a home like environment, and this care is delivered in a caring manner. Resident’s visitors and visiting professionals spoke very positively of the home and the service provided by staff. The food provided was well received and focuses on home cooking. Hazelmere provides a home like environment where visiting is encouraged with some visitors spending long periods of time in the home. Hazelmere Nursing Home DS0000013994.V345607.R01.S.doc Version 5.2 Page 6 The care needs of residents are fully assessed following admission and care is planned on an individual basis. Mrs Gadsden is well respected and has a close relationship with residents and their relatives. Staff feel comfortable and able to discuss any issue with her at any time. What has improved since the last inspection? What they could do better: The home needs to confirm in writing to the prospective resident or their representative that with regard to the needs assessment completed the home can meet the needs of the prospective resident. This ensures that decisions around admission to the home are informed. In addition Mrs Gadsden needs to fully document any pre admission assessments to evidence a multi-disciplinary approach. Further attention needs to be focussed on meeting residents individual choices and preferences along with assessing residents risk of falls and need to be recorded and attended to fully. The medication practices in the home needs to be improved with clear complete and meaningful records being maintained and with best practice being followed to ensure safest medicine practice is maintained. The call bell system needs to be improved to ensure any residents wanting to call for help can do so. The recruitment practice of the home needs further improvement and should always include appropriate referencing and the retention of the required documentation to demonstrate a thorough and robust recruitment procedure. Hazelmere Nursing Home DS0000013994.V345607.R01.S.doc Version 5.2 Page 7 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 Nursing Home DS0000013994.V345607.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 Nursing Home DS0000013994.V345607.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): 1, 3 and 6 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides prospective residents and relatives, with a good level of information about the home, its facilities, services and the costs involved. The admission procedures allow for the needs of prospective residents to be assessed by a competent person before admission although people are not assured in writing that their needs will be met and the assessment process does not demonstrate a multi-disciplinary approach. EVIDENCE: On arrival at the home it was noted that the registration certificate was displayed in the front entrance area of the home. Hazelmere Nursing Home DS0000013994.V345607.R01.S.doc Version 5.2 Page 10 The statement of purpose was located in the office and this document is also used as the service users guide. The home also has a small brochure that is given out to people wanting to retain information on the home. The statement of purpose has been updated since the last inspection and now contains the required information. A relative spoken to confirmed that he was given relevant information on the home before his mother was admitted, and visited the home and viewed the bedroom that was available. He was satisfied with the way his mother was admitted to the home and was glad to get a place, as he understood that there was a waiting list. An assessment of the admission process followed included the review of the documentation relating to the last two admissions to the home. This confirmed that once an enquiry is made details are recorded including relevant information about the prospective resident, and the person making the enquiry who is usually a family member. This is then followed up if the home has a vacancy and it is confirmed that the home may be suitable with an assessment of the prospective resident completed by Mrs Gadsden. Records seen confirmed the process followed however the assessments of need completed were not signed and did not record a multi-disciplinary approach to the assessment or where the assessment was completed. Despite this Mrs Gadsden said that when completing the assessment she does take into account the hospital staff views and that relatives are given the opportunity to have an input into the process. Once completed Mrs Gadsden advises the prospective resident or their representative taking in to account the assessment if the home is able to meet their needs. This is not currently confirmed in writing in accordance with the required documentation and this was discussed during the inspection visit. Intermediate or rehabilitative care is not provided at Hazelmere Nursing Home. Hazelmere Nursing Home DS0000013994.V345607.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): 7, 8, 9 and 10 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The care documentation provides a framework for the provision of care it however needs to be extended to cover individual choices and preferences. Resident’s care needs are met taking into account resident’s dignity with evidence of regular input from health care professionals as necessary. The medicine administration practice in the home does not ensure best and safest medicine administration practice is followed and records are not always complete or meaningful. EVIDENCE: Two individual plans of care were reviewed in depth as part of the inspection process and confirmed that these provided a basic framework for staff to follow. This framework focussed on the physical care needs of residents and individual choices and preferences were not clearly recorded. Individual assessments are also held on file with evidence that the plans of care are Hazelmere Nursing Home DS0000013994.V345607.R01.S.doc Version 5.2 Page 12 reviewed on a monthly basis. Some care plans are far more structured and clearer than others and further attention needs to be given to ensuring a good standard is maintained throughout. The care documentation includes a moving and handling assessment, bed rail risk assessments and nutritional assessments. The nutritional assessment used referred to associated guidelines however the guidelines were not available in the home and Mrs Gadsden said that she would contact the Dietician and get the relevant manual. The risk of falling is not separately assessed and advice was given on contacting relevant bodies for further guidance. Daily records are maintained and the care documentation recorded the pressure area care provided and indicated that pressure sores that a resident came to the home with were healed and a resident with a developing pressure sore was receiving appropriate care. The care documentation did not demonstrate that residents or their representatives are involved in the planning of care and this was discussed with Mrs Gadsden who said that this was in fact done but not always recorded. Clear records to confirm the involvement of other health care professionals and regular contact with doctors was seen and on the day of this visit one doctor visited the home as one resident was ‘not feeling as good as she had been’ and staff had noted a general deterioration in her condition. The nurse in charge arranged for the doctor to visit and discussed the matter with the resident’s daughter. Resident’s weights are recorded regularly along with other clinical observations, which are used to recognise and respond to health needs. Two relatives met with spoke positively about the way the home had responded to the health care needs of residents both saying that their relative’s health had greatly improved since their admission to Hazelmere Nursing Home. All comments about the care provided in the home were positive one resident saying ‘I could not be in a better place TLC everywhere they all care and there is a lovely happy atmosphere in the home’. Observation in the home again confirmed that staff do not use handling belts and support residents when moving them under their arms that can cause injury and discomfort. This matter was again raised with Mrs Gadsden and she said that she would ensure staff received further training from an outside trainer to ensure safe practice is followed. It was again noted that the registered nurses who administer all the medicines in the home are not following the homes procedure for administration. Staff choose to administer medicines by potting them up and administering without the medicine record being present. Mrs Gadsden said that each registered nurse retains his or her own accountability for safe practice but acknowledged that this was not best practice. Hazelmere Nursing Home DS0000013994.V345607.R01.S.doc Version 5.2 Page 13 In addition when the medicine records were reviewed it was noted that the records were not complete with gaps identified in a number of areas. Mrs Gadsden agreed to follow up this matter with the registered nurses concerned. Ticks rather that signatures were also being used to record the administration of eye-drops and creams and this does not provide a meaningful record and staff need to ensure clear records are maintained. Mrs Gadsden confirmed that all medicines are now disposed off through a licensed disposal company and that the homes procedures had been updated to reflect this. Residents were seen to be spoken to in a pleasant way by staff with resident’s choices being responded to. Resident’s rooms were found to be individual and homely and respected as their own space. During the visit it was seen that residents are transported to the toilet on a wheeled commode this was discussed with Mrs Gadsden who said that this was used for practical reasons, clearly this should be kept to a minimal to promote residents dignity. Hazelmere Nursing Home DS0000013994.V345607.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): 12, 13, 14 and 15 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Links with friends and relatives are encouraged and choices made are respected. Resident’s opportunities for stimulation through leisure and recreational activities are not yet fully developed in the home to meet individual needs. Residents receive a wholesome and appealing diet. EVIDENCE: Contact with residents and visitors to the home identified that the activity provision and social interaction in the home is the area that needs to be improved. The homes own quality-monitoring system has also identified this shortfall and Mrs Gadsden is responding to this feedback. She has given a staff member a specific responsibility in assessing and developing individual activity including more one to one contact and group activity when possible. This Hazelmere Nursing Home DS0000013994.V345607.R01.S.doc Version 5.2 Page 15 member of staff is supported by a previous visiting relative now employed with a specific interest in promoting social activity. The communal space does not promote social interaction for example it was noted that two residents who were sitting next to each other found it difficult to talk as the positioning of their chairs meant that they could not see each other, in addition it was noted that the Television was on throughout the day of the inspection visit dominating the only communal room in the home. Ways of improving the environment for social interaction should also be considered. Visitors spoken to again confirmed that they are very well received by the staff at Hazelmere and feel comfortable to visit as much as they want to, some visiting every day. One visitor said that she was greeted as an ‘old friend’. Visiting times are not restricted and visitors can stay for a meal if they wish. Some links with the community are maintained including links with the church if wanted. Residents are able to have their own possessions in their rooms and information about advocacy is included in the statement of purpose/ service users guide. There are set routines and times in the home however some flexibility is introduced in response to resident choice, these areas are not explored fully in the care documentation and should be recorded. For example the times residents would choose to go to bed when and where and if they would like to watch the television and if they want to use a bib or a napkin. The meals were well complimented and there is strong emphasis on quality home cooking with fresh produce. Residents who have difficulty in chewing had their meals individually liquidised and staff assisted residents in a quiet appropriate manner if needed and were watchful to ensure residents were eating well and enjoying their meal. Relatives commented on how resident’s appetite had improved since admission and residents were seen to be eating well, and to be provided with adapted appliances to promote their independence. The inspector again noted that residents sit at individual tables and there is no feeling of a social event at mealtimes. Most residents were also dressed in bibs when eating and not given a napkin as an alternative. Hazelmere Nursing Home DS0000013994.V345607.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has a suitable procedure for dealing with complaints made to it. The home’s procedures do not ensure that the correct alerting procedures are followed once an allegation or suspicion of abuse is highlighted. EVIDENCE: A new complaints procedure has been provided and this is available within the statement of purpose /service users guide and is displayed in the entrance hall area. Everyone spoken to felt confident that if they had a concern and raised it with a registered nurse that it would be dealt with promptly and effectively. Mrs Gadsden confirmed that there had not been any complaint that needed to be recorded since 2000 and any issue raised is dealt with quickly to ensure people felt the matter had been attended to without raising a formal complaint. Complaints made would be recorded in a book allocated for this purpose only, and available in the office. Discussion took place around the need to ensure confidentiality of any complaints made. Mrs Gadsden said that the homes Adult Protection procedure had been updated although this was not available in the home. Discussion took place around the new local Safeguarding Vulnerable Adults procedures and the need for the home to use these. Hazelmere Nursing Home DS0000013994.V345607.R01.S.doc Version 5.2 Page 17 There was evidence that staff were receiving training on prevention of abuse from a registered nurse working in the home and discussion with this nurse following the inspection visit confirmed that she had a good understanding of Safeguarding Vulnerable Adult’s procedures. The homes updated procedure was forwarded to the CSCI after the inspection assessment visit. Hazelmere Nursing Home DS0000013994.V345607.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20,22 and 26 People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides residents with a comfortable safe environment that has a home like feel and meets the stated purpose of the home. EVIDENCE: Hazelmere Nursing home is a converted premise that has retained a home like environment. Accommodation is provided on two floors with disabled access to the first floor via a passenger shaft lift. People spoken to commented on the friendly and homely atmosphere that is enjoyed at the home by staff, residents and visitors. Window and carpet replacement has been progressed since the last inspection and the home continues to be well maintained and decorated. Hazelmere Nursing Home DS0000013994.V345607.R01.S.doc Version 5.2 Page 19 There is a large garden with wheelchair access to the rear of the home and residents said how much they like sitting in the garden. The home only has one communal space room and this was found to be rather cramped with wheelchairs and hoists around the dining table. The main focus of the room is the television and chairs are placed around the room in rather a regimented fashion with residents having set chairs to sit in. It can also be difficult for visitors when wanting to talk to a resident as space and privacy is limited. Mrs Gadsden confirmed that visitors are given the option to use resident’s own bedrooms, as a private separate room is not available in the home. It could be possible to re-organise this room to provide separate areas for different activity and social interaction. The character and facilities in the communal areas were found to be domestic and home like. It was however again noted at this inspection that residents have to call out for attention and residents said that they are not always heard. It is imperative that residents are able to summon assistance when they need it and suitable call facilities must be available to them. The home was found to be clean and hygienic throughout and Mrs Gadsden had new information on infection control in care homes from the Department of Health and said tat she was reviewing practice in accordance with this. Residents and relatives said that their laundry is well managed. Hazelmere Nursing Home DS0000013994.V345607.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. There is sufficient staff who are suitably trained on duty to ensure that residents receive the level of care they need. Residents are not fully protected by the home’s recruitment practices. EVIDENCE: At the time of this inspection visit there was 21 residents living in the home and the staffing arrangements were seen to be adequate and people spoken to said that there appeared to be enough staff although the staff were always very busy. A staff rota was available for inspection and confirmed that a Registered Nurse is working in the home over the 24 hours with 4 carers in the morning and 3 carers in the afternoon and 1 at night. There are in addition sufficient catering and cleaning staff. The staffing team is very stable and everyone appreciated this, as the team knew each other and the resident very well. All feedback received from residents and visitors confirmed that the staff and Mrs Gadsden are well thought of, residents comments included ‘Very nice staff, I could not fault Hazelmere Nursing Home DS0000013994.V345607.R01.S.doc Version 5.2 Page 21 them’ ‘I am quite happy here and I enjoy living here everyone is kind and friendly and they chat to you’ ‘I am happy here staff are all very kind’. The recruitment files pertaining to the three staff were reviewed as part of the inspection process and identified that the recruitment practice still needs to be improved in certain areas and the following shortfalls were identified. • • • Not all staff records include a recent photograph. Not all staff records include proof of identity. References are not always obtained from the last or current employer. Staff training is co-ordinated by a registered general nurse working in the home. She is able to work closely with the staff and provide supervision and practical observation and raining. She is aware of the ‘Skills for Care’ induction training and is working towards establishing these. Staff training is far more organised and the new carer spoken to confirmed that she ‘had a thorough induction training that was very interesting’. Mrs Gadsden confirmed that 18 of care staff have completed a National Vocational Qualification in care level 2 with a further two members of staff completing this. Hazelmere Nursing Home DS0000013994.V345607.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home was found to be managed in a friendly manner with Mrs Gadsden providing clear leadership. Resident’s financial interests are safeguarded and the quality of care services is monitored and responded to. The health, safety and welfare of residents and staff are generally promoted and protected. EVIDENCE: Mrs Gadsden is the registered manager and joint owner of Hazelmere Nursing Home with her husband for the past seven years. She is a registered general Hazelmere Nursing Home DS0000013994.V345607.R01.S.doc Version 5.2 Page 23 nurse and has managed homes previously and has also completed relevant management training. Mrs Gadsden is very involved in all aspects of the homes management and has a close working relationship with all staff. She is well respected by them and relatives spoken to and is know and addressed as ‘Matron’. The care that she leads is very nurse led although she not only wants to meet the health care needs of the individual she hopes to provide a loving environment caring as a close relative would. Resident /relative questionnaires were completed in April 07 and these provided some positive feedback with the only concern identified being a lack of suitable activities in the home. Mrs Gadsden is responding to these views with more one to ones and general group activity being provided. She also confirmed that she would be using further questionnaires to assess if the changes that she has initiated have improved outcomes for residents. A quality-monitoring manual provided by a professional consultancy group is also completed to assess the homes compliance with the National Minimum Standards. Mrs Gadsden confirmed that the home has no dealings with resident’s monies and that any extra costs incurred are paid by the home and then individually invoiced on a monthly basis. In addition she also confirmed that all the health and safety policies procedures had been updated and that all checks have been completed with regard to Health and safety in the home. Hazelmere Nursing Home DS0000013994.V345607.R01.S.doc Version 5.2 Page 24 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 3 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X 2 X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Hazelmere Nursing Home DS0000013994.V345607.R01.S.doc Version 5.2 Page 25 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 OP3 Regulation 14(1) Requirement That the registered person if wanting to admit someone confirms in writing that having regard to the assessment made on the prospective resident that the home can meet those needs. That the care plans record individual choices and preferences and include the use of individual risk assessments for residents at risk of falling. That all staff follow the homes medicine policies and procedures to ensure best and safest practice is followed at all times. (Outstanding from last inspection) That medicine records are maintained to provide complete and meaningful records. That the communal space is provided with an adequate call bell system to ensure residents wanting assistance are able to summon help. That a thorough recruitment procedure is operated that includes securing two DS0000013994.V345607.R01.S.doc Timescale for action 01/09/07 2. OP7 15(2) 01/10/07 3. OP9 13(2) 01/09/07 4. OP22 23(1) 01/10/07 5. OP29 19(1) 01/10/07 Hazelmere Nursing Home Version 5.2 Page 26 authentic/appropriate references and the retention of documentation as identified in schedule 2.which includes a recent photograph and evidence of identity. (Outstanding from previous 3 inspections) 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. 1. Refer to Standard OP3 OP20 OP22 OP22 Good Practice Recommendations That the pre admission assessment demonstrates that prospective residents their representatives and relevant professionals are party to this assessment. That the communal space area is re-organised so that the space can be used more flexibly. That suitable chairs are provided so that those residents wishing to sit at a dining room to eat are able to do so. That an assessment of the premises and facilities should be undertaken by a suitably qualified person, or qualified Occupational Therapist, to advise on the suitability of disability equipment and environmental adaptations. That a training Matrix is used to record and plan all training within the home. 2. OP30 Hazelmere Nursing Home DS0000013994.V345607.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Hazelmere Nursing Home DS0000013994.V345607.R01.S.doc Version 5.2 Page 28 - 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. 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