Inspection on 06/09/06 for Care Homes UK Ltd T A Hazelroyd Nursing Home

This inspection was carried out on 6th September 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 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

Care Homes UK Ltd T A Hazelroyd... 21/04/09

Care Homes UK Ltd T A Hazelroyd... 20/05/08

Care Homes UK Ltd T A Hazelroyd... 07/11/07

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

CARE HOMES FOR OLDER PEOPLE Hazelroyd Nursing Home Hazelroyd Nursing Home 31 - 33 Savile Road Halifax Lead Inspector Paula McCloy Unannounced Inspection 6th September 2006 08:45 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 Hazelroyd Nursing Home DS0000065574.V304006.R02.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. Hazelroyd Nursing Home DS0000065574.V304006.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hazelroyd Nursing Home Address Hazelroyd Nursing Home 31 - 33 Savile Road Halifax 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) 01422 362325 01422 300575 Care Homes UK Ltd. Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Hazelroyd Nursing Home DS0000065574.V304006.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection This was the first inspection of the home since the new owners took over in February 2006. Brief Description of the Service: Hazelroyd is a large stone built property that has been adapted and extended for its current use. It is situated on Savile Park Road and is approximately 10 minutes walk from Halifax town centre and its amenities. There is car parking to the front and rear of the building. There is a patio area to the rear of the house where residents can sit out in fine weather. Hazelroyd is a care home with nursing. It has the provision to accommodate a total of 40 older people. The accommodation is arranged over four floors. Hazelroyd has three lounges, a small dining room and conservatory. The conservatory is the designated smoking area for residents. There are twelve single bedrooms and fourteen double bedrooms. One of the double bedrooms has an en suite toilet. There are seven bathrooms, four of which have assisted bathing facilities and there are five separate toilets. There is a passenger lift that serves all four floors. The current charges at Hazelroyd range from £415 - £432 per week. Additional charges are made for hairdressing and chiropody. Hazelroyd Nursing Home DS0000065574.V304006.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk This was the first inspection of Hazelroyd since the new owners took over the home in February 2006. One complaint has been received by the Commission for Social Care Inspection since the new owners took over. The complaint was about adult protection procedures in the home not being followed. (see section on Complaints and Protection). This inspection was carried out to assess the home against the a predetermined selection of the National Minimum Standards for Older People and to check what progress had been made on meeting the requirements from the previous inspection visits. One inspector carried out the inspection over 1 day and spent approximately 7.5 hours in the home. The methods used in this inspection included discussions with 5 residents, 2 relatives, 9 staff, observation of care practice, examination of records, and a partial tour of the home. A pre-inspection questionnaire was sent to the home prior to this inspection visit asking for information. This questionnaire was returned to the Commission for Social Care Inspection and the information provided has been used in this report. Hazelroyd Nursing Home DS0000065574.V304006.R02.S.doc Version 5.2 Page 6 Comment cards were sent to residents, relatives and GP’s; these cards provide an opportunity for people to share their views of the service with the CSCI. Comments received in this way are shared with the provider without revealing the identity of those completing them. Two residents, three relatives and one GP wrote to the inspectors with their comments. What the service does well: The homes admission procedures are good. Any prospective resident is fully assessed before they move into the home. This ensures that their care and support needs are planned for and can be met. Prospective residents or their families are encouraged to visit the home so they can assess the suitability of the facilities for themselves. Individual care plans are detailed and give staff the information they need to look after residents properly. Doctors and other professionals are involved as necessary and residents health care needs are met. Residents are asked about their preferred routines and staff respect these. Activities are being organised on a regular basis, including trips out. Some residents are looking forward to a trip to Blackpool to see the illuminations. Residents said that the meals are good. Relatives said they are made to feel welcome and some have a meal when they visit. If residents and/or relatives are not happy about the service they are getting the home has a complaints procedure. Residents and relatives were aware of the procedure and said that they would be able to raise any concerns and that they felt and problems would be resolved. Staff are being properly checked before they start work at the home, this makes sure they are suitable to work with older people. There are enough staff on duty to make sure residents needs are met. The home is clean and comfortable. The new owners are looking at how they can improve the facilities for residents. Some residents appreciate the designated smoking area. Hazelroyd Nursing Home DS0000065574.V304006.R02.S.doc Version 5.2 Page 7 Residents and relatives are consulted about the way the home is run and about the facilities. Their comments have been listened to and the home is writing to them to let them know how they intend to improve things at the home. What has improved since the last inspection? 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. Hazelroyd Nursing Home DS0000065574.V304006.R02.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 Hazelroyd Nursing Home DS0000065574.V304006.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 & 5 standard 6 does not apply. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home needs to make sure that they have additional information to go with the existing brochure to make sure residents have all the key facts about the home. The home’s admission procedures are good. Any prospective resident is fully assessed before they move into the home. This ensures that their care and support needs are planned for and can be met. Prospective residents and/or their families are encouraged to visit the home so they can make an informed decision about the suitability of the home. EVIDENCE: The home must have a Statement of Purpose that sets out the aims, objectives, philosophy of care etc, as detailed in Schedule 1 of the Care Homes Regulations 2001. This document was not available at this inspection. Hazelroyd Nursing Home DS0000065574.V304006.R02.S.doc Version 5.2 Page 10 There is a brochure for the home that gives some information about the facilities and care provided at the home. This in itself does not provide all of the information that any prospective resident should be given. The home needs to ensure that residents receive an up to date ‘service users guide’ with the brochure so that they have all of the necessary information about the home. Residents get a terms and conditions of residence document that sets out the fees payable, the room to be occupied etc. Five residents confirmed that they had received this document and copies were evident in residents care plans. Individual records are kept for each of the residents. The records for the two most recently admitted residents showed that staff from the home had completed a full assessment of their needs before they had been admitted to the home. This information had then bee used to formulate the care plans to ensure that the residents identified needs were met. Staff said that they encourage prospective residents to come and have a look around the home, although it is more usual for relatives to do this. This gives people the opportunity to see the home for themselves and to decide if it is suitable for them. The home does not provide intermediate care. Hazelroyd Nursing Home DS0000065574.V304006.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Individual care plans are detailed and give staff the information they require to meet residents’ needs. The health care needs of residents are being met with health care professionals being involved as necessary. Residents’ medication is well managed which promotes good health. EVIDENCE: Care plans are well organised and it is easy to find relevant information quickly. The care plans set out in detail what action needs to be taken by staff to ensure residents’ needs are met. Staff are vigilant and new care plans are developed as peoples needs change. Details of residents’ interests and preferred routines are also noted. Care plans are being reviewed on a monthly basis and there was some evidence of residents and relatives being involved in the planning process. For example staff involved the tissue viability nurse for advice about one resident, who was identified at being at risk of developing pressure sores. The resident didn’t like the specialist mattress that was Hazelroyd Nursing Home DS0000065574.V304006.R02.S.doc Version 5.2 Page 12 provided so staff involved the tissue viability nurse again to find a mattress that the resident was happy with. Care plans are being reviewed on a monthly basis. Five relatives said they were kept up to date about their relatives well being and that they are consulted about their relatives care. The reviews tend to be based around reviewing the individual elements of the care plan. The reviews would be better if they were more holistic, taking into account the overall care package and residents’ satisfaction with their care and support. Care staff have access to the care plans and are contributing to the written records about the care they are delivering. Care staff confirmed that they read the care plans and that the nursing staff keep them up to date when residents needs change. Residents’ health care needs are being identified and met. Staff are vigilant and GP’s and other health care professionals are being involved as necessary. Details of any visits by health care professionals are clearly documented in the residents care plan, together with the advice that has been given. There was clear evidence in one residents care plan that the advice from the tissue viability nurse was being followed. During the inspection staff contacted a GP to arrange a visit to a resident who had become poorly during the morning. The GP visited and treatment was prescribed. Comments from one GP confirmed that staff understand the care needs of residents and that they seek advice appropriately. The medication system is well managed. Residents get their medication at the prescribed times and the records are well maintained. Any fortified drinks that are prescribed by doctors are signed for on the medication sheets, so it is clear that residents are receiving these. Residents looked smart and well cared for. All residents spoke well of staff and they all felt they were kind and caring. This view was also shared by relatives. From observation staff carried out any personal care in a discreet and respectful way. Relatives and GPs confirmed that they were able to visit their relatives/patients in private. Hazelroyd Nursing Home DS0000065574.V304006.R02.S.doc Version 5.2 Page 13 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): 12, 13, 24 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Social activities are provided for both groups and individual residents to keep them stimulated. Service users preferences’ in relation to the routines of daily living are respected. Relatives and friends feel welcome to visit at any time. The meals at the home are good and residents are consulted about the choice of meal available. EVIDENCE: Service users preferences’ in relation to the times they want to get up and go to bed are respected by staff. It was noted that service users were getting up at varying times during the morning. All of the staff said that residents can follow their own routines. Care plans contain information about residents’ individual interests. There was evidence from staff that they know about these and that they support residents to maintain these interests. For example one resident spends a lot of time in her room and has a love of music. Staff said that they put her favourite CD’s on for her in her room. Another resident likes to listen to the radio. He has a radio in his room and selects the programmes he wants to Hazelroyd Nursing Home DS0000065574.V304006.R02.S.doc Version 5.2 Page 14 listen to. Care staff provide activities in the mornings and in the afternoons, these may include group activities like dominoes or trips out of the home. Staff said that residents have been out to the pub, local park and into Halifax town centre. There is a trip to Blackpool planned for the end of September. Currently there is very little recorded in care plans about the activities people have participated in. This is an area that care staff could be more involved in and contribute to the written records. Relatives confirmed that they can visit at any time and that they are made to feel welcome. One relative said that they are always offered a drink and a meal at the home. Visits take place in the communal areas, the dining room or in service users bedrooms if they want to be private. There are three lounges in the home and the conservatory is the designated smoking area. Residents can choose the lounge that suits them the best. Service users stated that the food was good. The menus are displayed in the dining room. There is a choice available for every meal. The cook has a list of residents’ likes and dislikes. Service users have their meals in a number of different rooms. The delivery of meals at lunchtime was well organised. From observation staff were available to supervise and assist residents. Hazelroyd Nursing Home DS0000065574.V304006.R02.S.doc Version 5.2 Page 15 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 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home needs to make sure that everyone knows about the complaints procedure and what to do if they are unhappy about the service they receive. The home needs to make sure that all staff understand how to make sure residents are protected from any kind of abuse. EVIDENCE: The home has a complaints procedure. It is not on display and information about how to complain is not in the homes brochure. This information must be included in the ‘service users guide,’ so that everyone knows what to do if they are unhappy about the service they get. Relatives and residents said that they knew who to talk to if there was anything they were unhappy about. The complaints log showed that three complaints have been received by the home. These have all been dealt with appropriately. One complaint has been made to the Commission for Social Care Inspection this was in relation to an adult protection incident at the home involving allegations made about a member of staffs conduct. The home did not follow their procedure in this instance, which states that if an allegation is made about a member of staff that they should be suspended whilst the allegation is investigated. Following the complaint the home was contacted by the Commission for Social Care Inspection and they then took appropriate action and the member of staff in question was suspended. From talking to staff on Hazelroyd Nursing Home DS0000065574.V304006.R02.S.doc Version 5.2 Page 16 this visit they are all much clearer about adult protection issues and the procedures that must be followed. They have learnt from this recent experience and all of the staff spoken to were very clear about the action they must take as individuals if they feel any practices in the home are not in the best interests of residents. The home must organise training for staff about using the adult protection procedures and identifying and reporting abuse, so they are confident to use the procedures should the need arise. Hazelroyd Nursing Home DS0000065574.V304006.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home is clean and comfortable. The owners are planning to make improvements to the building and improve the facilities for residents. They are currently working with an architect to see how this can best be achieved. EVIDENCE: The home is located close to Halifax town centre and all of its amenities. There is a patio that residents can use in fine weather and car parking facilities to the front and rear of the building. The new owners have plans to up grade the facilities at the home and are currently working with an architect to see how the accommodation can be improved. Some new equipment has already been purchased and installed. There is a new gas range in the kitchen and a macerator in the upstairs sluice to dispose of incontinence pads. Hazelroyd Nursing Home DS0000065574.V304006.R02.S.doc Version 5.2 Page 18 The home was clean and tidy on the day of the visit and residents and relatives confirmed that this was usually the case. The laundry is located in the basement and is well equipped. The laundry assistant was very pleased to have a new iron, which she said is making her job easier. Hazelroyd Nursing Home DS0000065574.V304006.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Staff morale is generally good and staff are working positively to improve service users quality of life. Staff are receiving appropriate training to meet service users needs. Any new staff are thoroughly checked to ensure that they are suitable to work with older people. EVIDENCE: At the time of the inspection there were 23 residents living at the home. The duty rotas were examined. These show that during the day there is one nurse on duty with four care assistants during the day. At night there is one nurse and two care assistants on duty. There is cook, domestic and kitchen assistant cover during the day. The laundry assistants works seven mornings per week. Staff said that at the current time the numbers of staff on duty were adequate to meet residents needs. Staffing levels need to be kept under review as residents needs change and the number of residents in the home increase. All staff spoken to felt that they were working well as a team and that they enjoyed coming to work. New members of staff said that they had been made to feel welcome and were enjoying working at the home. Hazelroyd Nursing Home DS0000065574.V304006.R02.S.doc Version 5.2 Page 20 Recruitment procedures at the home are robust. Staff files confirmed that the necessary checks are being completed to ensure the suitability of new staff. All staff spoken to confirmed that they had received contracts of employment, since the new company had taken over the home. There are 20 of the care staff qualified to NVQ level 2 or 3. A further 2 members of care staff are in the process of completing this training. Staff said that there were plans for more care staff to enrol on this training. Recently staff have received moving and handling, food hygiene and health and safety training. Hazelroyd Nursing Home DS0000065574.V304006.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home does not have a registered manager, however, the current management arrangements are making sure that the home is being run in the best interests of residents. Practices in the home generally promote the health, safety and welfare of the residents. EVIDENCE: There is no registered manager at the home. The home have advertised the post but have not managed to recruit a suitable candidate for registration. At the current time management responsibilities are being shared by one of the Hazelroyd Nursing Home DS0000065574.V304006.R02.S.doc Version 5.2 Page 22 senior nurses, the company’s director of nursing and the administrator. Most staff seemed to be clear about the role of each of these people. Residents and relatives have recently been consulted about the running of the home via the quality assurance questionnaires. The results of this survey have been analysed and the issued raised have been addressed in the homes response. For example people thought that that the patio area looked neglected. The home intend buying new patio furniture and some flower tubs and hanging baskets. The results of the survey are going to be circulated to residents and relatives. The owners must also undertake monthly visits to the home and as part of these visits talk to residents relatives and staff about the service provided. Written reports of these visits must also be prepared and be available at the home. The administrator does hold money on behalf of residents. The records examined were well maintained and accurate. There is a written Health and Safety policy. Staff receive moving and handling, food hygiene, fire safety, first aid and infection control training. The fire alarms are not being tested on a weekly basis. These tests must be completed to make sure that the alarm system is working properly. Fire drills/practices are held. The passenger lift and moving and handling equipment service records were all seen and were up to date. The home did not inform the Commission for Social Care Inspection about the adult protection issue in the home. Staff must make sure that they inform the Commission for Social Care Inspection of all notifiable incidents as listed in Care Homes Regulations 2001, regulation 37. Hazelroyd Nursing Home DS0000065574.V304006.R02.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 1 3 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 2 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Hazelroyd Nursing Home DS0000065574.V304006.R02.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? N/A 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 OP1 Regulation 4 Timescale for action The Statement of Purpose for the 30/11/06 home must be available. Staff should refer to schedule 1 of the Care Homes Regulations 2001 to ensure that this document contains all of the required information. An up to date ‘service users 30/11/06 guide’ that contains all of the required information must be available to all residents/ prospective residents. Adult protection training for all 31/10/06 staff must be arranged. Care staff must continue with 31/03/07 NVQ training in care in order to achieve the standard of having 50 of the staff qualified to this level. The owners must complete a 31/10/06 formal monthly visit to the home and compile a report regarding its conduct. The fire alarm system must be 30/09/06 tested on a weekly basis and written records kept of these tests. Staff at the home must report 30/09/06 notifiable incidents to the DS0000065574.V304006.R02.S.doc Version 5.2 Page 25 Requirement 2 OP1 5 3 4 OP18 OP28 13 18 5 OP33 26 6 OP38 23 7 OP38 37 Hazelroyd Nursing Home Commission for Social Care Inspection within 24hrs of their occurrence. 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 OP7 Good Practice Recommendations Monthly care plan reviews should be developed further so they become more holistic, taking account of the overall care package and residents satisfaction with their care and support. Records of the activities that residents participate in should be recorded. 2 OP12 Hazelroyd Nursing Home DS0000065574.V304006.R02.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB 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 Hazelroyd Nursing Home DS0000065574.V304006.R02.S.doc Version 5.2 Page 27 - 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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