Inspection on 24/07/06 for Hazelwell Lodge

This inspection was carried out on 24th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Hazelwell Lodge 07/06/07

Hazelwell Lodge 27/01/06

Hazelwell Lodge 01/09/05

Hazelwell Lodge 12/01/05

Hazelwell Lodge 21/06/04

Hazelwell Lodge 29/01/04

Hazelwell Lodge 14/05/03

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

CARE HOMES FOR OLDER PEOPLE Hazelwell Lodge 67 Station Road Ilminster Somerset TA19 9BQ Lead Inspector Jane Poole Key Unannounced Inspection 24th July 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 Hazelwell Lodge DS0000016068.V301353.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. Hazelwell Lodge DS0000016068.V301353.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hazelwell Lodge Address 67 Station Road Ilminster Somerset TA19 9BQ 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) 01460 52760 01460 52384 MISS FEDILIA MAXWIN Mrs Nicola Ann Overd Care Home 35 Category(ies) of Dementia - over 65 years of age (0), Old age, registration, with number not falling within any other category (0) of places Hazelwell Lodge DS0000016068.V301353.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. REGISTERED FOR 35 OLDER PERSONS IN CATEGORIES OP AND DE (E). 27th January 2006 Date of last inspection Brief Description of the Service: Hazelwell Lodge is a late Victorian property with a purpose built extension to the rear and an enclosed garden to the side. The home is situated at the edge of the small town of Ilminster, close to local amenities. The home accommodates 35 people in two separate areas of the building. The Bay provides personal care for older people and specialises in care for older persons with dementia care needs. The Lilies provides personal care for older people with dementia care needs and is accredited by Somerset Mental Health and Social Care Partnership under the Specialist Residential Care (SRC) arrangements. The Lilies is supported by a development nurse from the mental health care services. Platinum Care operates the home on behalf of the proprietors. Hazelwell Lodge DS0000016068.V301353.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out by Jane Poole and Steve Humphreys over a 7.5 hour period. The inspectors were made welcome in the home, were able to talk with staff and service users, tour the building, observe care practices and view records. 8 Comment cards were received from relatives/visitors prior to this inspection and some comments have been incorporated into this report. Many of the service users living at Hazelwell Lodge are not able to fully express their views due to their dementia. The inspectors observed that service users were well presented, appeared content and animated and moved freely around the home. What the service does well: What has improved since the last inspection? Hazelwell Lodge DS0000016068.V301353.R01.S.doc Version 5.2 Page 6 Since the last inspection staff have received training in the protection of vulnerable adults. The home continues to improve and redecorate areas of the home. The upstairs bathroom has been totally refurbished to provide a pleasant room. The garden continues to improve and now offers service users a spacious colourful area. There are numerous seating areas and service users were observed using the garden throughout the day. What they could do better: Assessments of service users needs were not comprehensive. Pre admission assessments did not cover likes, dislikes or preferred routines. There was limited information in care plans to enable staff to carry out person centred care. Some areas of the home still require refurbishment, in particular the laundry. This room is extremely small and the only sink is a very small wash hand basin, there is no soap or paper towels at the basin meaning that laundry staff have to use the facilities in the bathroom opposite to wash their hands. There are no sluice facilities in the home, commode pots are emptied in toilets and washed in communal baths. Upstairs two rooms have been made out of one larger room, the room is poorly divided with walls not reaching the ceiling and each room having half a window and half a radiator. The home has carried out a review of staffing levels, the review has determined that 3 staff are needed in the late evening and throughout the night to meet the needs of service users. Currently most nights the home still operates on 2 staff and relies on staff living at the home to provide sleep in cover. Sleep in cover is not marked on the duty rota although this was required at the last inspection. All staff would benefit from ongoing training and guidance in the care of people who have a dementia. Hazelwell Lodge DS0000016068.V301353.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. Hazelwell Lodge DS0000016068.V301353.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 Hazelwell Lodge DS0000016068.V301353.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 & 5. Overall quality in this outcome group is adequate. Service users and/or their representatives are able visit the home before making a decision to move in. The pre admission assessments carried out by the home are very basic and do not give information about the service users likes, dislikes or preferred routines. EVIDENCE: The home’s statement of purpose is available in the front hall. It was written in 2004 and would now benefit from updating to ensure that it fully reflects the services and facilities offered by the home. There is also a service user guide but this is not routinely given out to service users. Hazelwell Lodge DS0000016068.V301353.R01.S.doc Version 5.2 Page 10 All service users have a contract with the home, again this would benefit from updating to ensure that it is in line with standard 2 of the National Minimum Standards. A senior member of staff sees and assesses all prospective service users. Those who are planning to move into the Specialist Residential Care unit are also assessed by a member of the community mental health team. The inspectors viewed a sample of pre admission assessments carried out by the home. These assessments were extremely brief and did not give comprehensive information about likes, dislikes or preferred routines. This is particularly important, as some people living at the home are unable to fully express themselves. Some personal files contained copies of the full assessment carried out by professionals outside the home. Staff spoken to were confident that they were able to meet the needs of service users currently at the home. There is evidence that the home request re assessments of service users when they feel a persons’ care would be best met in an alternative environment. The night staffing levels in the home are not appropriate to meet the needs of service users. (See section 6) Service users and/or their representatives are able to visit the home before deciding to take up residence. On the day of the inspection two people were looking around the home. The home does not provide intermediate care. Hazelwell Lodge DS0000016068.V301353.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. Overall quality in this outcome group is adequate, however there are concerns about the low staffing levels in the late evening and throughout the night. (See staffing section.) Staff would be able to assist service users in a more person centred way if assessments and care plans placed a greater emphasis on likes, dislikes and preferred routines. Staff interact with service users in a respectful friendly manner. EVIDENCE: The inspectors sampled the personal files of 4 service users. All contained life histories which gave a varying degree of information about peoples preferred lifestyles. The life histories had been compiled in conjunction with family members. The assessments in the personal files were not comprehensive and it was therefore difficult to ascertain where information on care needs had been gained from. Specific care plans were in place for particular activities such as Hazelwell Lodge DS0000016068.V301353.R01.S.doc Version 5.2 Page 12 washing, dressing and eating. These plans of care were very detailed and personal to the individual. One person, who had been living at the home for almost three months, had no individual plans of care for any aspect of daily living meaning that there was no information to enable staff to assist with care in an appropriate manner. All service users had been assessed in respect of manual handling and tissue viability. Pressure relieving equipment was in place for a person assessed as being at high risk of pressure damage. There is a section in the personal file to record all professional appointments. These had not always been completed. For example the running records in respect of one service user stated that they had been seen by the GP but this was not recorded on the appointment sheet. Service users asked stated that staff helped them to attend appointments outside the home and arranged visits from a doctor or nurse if they were unwell. All service users are regularly weighed and records seen showed that people’s weight remained stable. There is a community development nurse who visits the home regularly to offer support and advice on mental health issues. The inspectors observed that throughout the day staff interacted with service users in a respectful and friendly manner. Staff were observed to knock on personal rooms before entering and assisted people with personal care in a sensitive manner. All service users were well presented, men were cleanshaven, clothes were clean and some service users were wearing jewellery. All 8 relatives/visitors who completed comment cards answered YES to the question “ Can you visit your relative/friend in private?” The home uses the Boots Monitored Dosage System for medication. There are appropriate storage facilities for all medication, including drugs that require refrigeration and controlled drugs. Medication Administration Records were found to be correctly signed when administered or refused. Some minor issues to promote good practice were discussed with the deputy manager at the time of the inspection. Hazelwell Lodge DS0000016068.V301353.R01.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 & 15. Overall quality in this outcome group is good. Service users have access to a wide range of activities and trips out. The quality and choice of food in the home is good. EVIDENCE: Service users are free to choose what time they get up, when they go to bed and how they spend their day. There is no information recorded about peoples preferred routines although social histories give varied amounts of information about peoples past lifestyles. On the day of the inspection one person had chosen to spend the morning in bed and this was respected by staff. An activity co-ordinator is employed who co-ordinates and supports activities in both units. There is a full activity programme that includes gentle exercise, live music, reminiscence, film shows, quizzes, reflexology, visits from PAT dogs and monthly trips out. Service users are free to join in with activities that interest them. Hazelwell Lodge DS0000016068.V301353.R01.S.doc Version 5.2 Page 14 On the day of the inspection several service users played boule in the lounge, one person did some gardening, another laid tables for lunch and some people watched TV or listened to music. One relative/visitor wrote on their comment card that they “would like to see more interaction between staff and residents.” Lack of interaction was not observed to be a major concern during the inspection but the home should continually monitor the situation and encourage social stimulation at all times. One service user goes for walks in the local area without staff support and many go out with friends or relatives. All 8 relatives/visitors who completed comment cards prior to the inspection stated that they were always made welcome in the home. The home does not act as an appointee or power of attorney for any service user. Small amounts of money are kept in the home to ensure that people are able to take part in trips and purchase small items if they wish to. Records were seen of these monies but they were not, on this occasion, checked against amounts held. There is a four week menu and the days meal is displayed in the dining room on each unit. On the day of the inspection there was one main meal and 3 alternatives. Service users are offered the choice at meal times. All service users observed appeared to enjoy their meal and it was noted that their was very limited waste. One service user who required help with eating was assisted in a very dignified manner. All service users, who were able to express an opinion, stated that the food in the home was good and that they received ample portions. Drinks were made available after lunch and at specified times throughout the day. It was suggested that due to the extremely hot weather jugs and glasses of cold drinks should be left out to enable people to help themselves. Hazelwell Lodge DS0000016068.V301353.R01.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. Overall quality in this outcome group is good. The home has taken reasonable steps to ensure that the risk of abuse to service users is minimised. EVIDENCE: The home has policies and procedures in recognising and reporting abuse, making a complaint and whistle blowing. Staff spoken to were aware of the ability to take serious complaints outside the home. The majority of staff have now received in house training in the protection of vulnerable adults in line with a recommendation made at the last full inspection. The management of the home are aware of their responsibilities and notify appropriate people if an issue arises. The homes complaints procedure is displayed in the home, however 3 of the 8 relatives/visitors who completed comment cards prior to the inspection answered NO to the question “Are you aware of the homes complaints procedure?” All staff are checked against the Protection Of Vulnerable Adults register before commencing work at the home and all undergo an enhanced Criminal Bureau check. Hazelwell Lodge DS0000016068.V301353.R01.S.doc Version 5.2 Page 16 The specialist residential care unit in the home is locked by an electronic keypad and professionals outside the home have assessed all as requiring this level of security. The inspectors observed that service users moved freely around the communal areas of the home and garden. All service users have unrestricted access to their personal rooms. Hazelwell Lodge DS0000016068.V301353.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24 & 26. Overall quality in this outcome group is adequate. Hazelwell Lodge provides a homely environment but some areas would benefit from updating. EVIDENCE: Hazelwell lodge is a large older style building, which has been extended to provide 34 rooms. One bedroom can be used for double occupancy but is currently being used as a single. Upstairs two rooms have been made out of one larger room, the room is poorly divided with walls not reaching the ceiling and each room having half a window and half a radiator. The home is divided into two units The Bay and The Lillies. The home is fitted with a fire detection system and all rooms have call bells. 14 of the bedrooms have en suite facilities and there are 5 bathrooms. (Information taken from pre inspection questionnaire.) All bedrooms have Hazelwell Lodge DS0000016068.V301353.R01.S.doc Version 5.2 Page 18 wash hand basins. Since the last inspection the upstairs bathroom has been refurbished to create a fresh and pleasant room. No aids or adaptations have been fitted in this room so it is currently only suitable for service users who are able to get in and out of the bath without assistance. Communal baths are fitted with thermostatic valves to prevent the risk of scalding. One bath tested was running at almost 50 degrees centigrade on the day of the inspection. This was discussed with the maintenance person and assurances were given that it would be adjusted. Throughout the home aids and adaptations have been put in place such as hand-rails, raised toilets and some assisted bathing facilities. There is some signage to assist people who are disorientated to find their way around the home independently. The inspectors viewed a sample of personal rooms and noted that service users are able to personalise their rooms, which gives them an individual and homely feel. Some rooms have been redecorated since the last inspection. Communal space is adequately furnished and domestic in style. Outside the home there is a large secure garden. This area continues to be developed to provide an attractive and useable space. Service users also have access to a garden area at the rear of the building, the ground here is uneven and there are sheds with old furniture etc stored outside. There are no sluice facilities in the home, commode pots are emptied in toilets and washed in communal baths. This is poor infection control practice. The laundry is extremely small for the size and nature of the home. There is one washing machine and two driers. The only sink in the room is a tiny wash hand basin. The laundry assistant stated that if any laundry required soaking then buckets had to be filled from the bathroom opposite. On the day of inspection all areas seen by the inspector appeared reasonably clean and fresh. It was noted that not all domestic staff wore aprons or overalls. Hazelwell Lodge DS0000016068.V301353.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Overall quality in this outcome group is poor. The home is not sufficiently staffed during the late evening and throughout the night to meet the needs of service users. Staff would benefit from ongoing training in the care of people who have a dementia. EVIDENCE: The home employs 24 Care staff, 12 of these staff have a National Vocational Qualification in care. 9 ancillary staff are also employed. (Figures taken from pre inspection questionnaire.) The deputy manager stated that the home usually has 6 carers on duty between the hours of 7.30am and 9.30pm. Duty rotas seen by the inspector show that this figure at times drops to 5. On weekdays a member of the management team and the activity co-ordinator are also on duty between 9am and 5pm. Overnight there is only 2 staff on duty. At a random inspection carried out on the 18th May 2006 it was required that this staffing level be reviewed to ensure that the staff were able to meet the needs of the service users throughout the day and night. The outcome of the homes review was that the home required 3 staff throughout the night but this has not yet been implemented. Hazelwell Lodge DS0000016068.V301353.R01.S.doc Version 5.2 Page 20 There are also 3 members of staff that live on the premises and are on call in case of emergencies throughout the night. A requirement of the last inspection was that sleep-in staff should be identified on the duty rota, this has not been implemented. The deputy manager gave assurances that live in staff have agreed to be on call each night but there is no documentation in staff personal files to evidence this. 50 of relatives/visitors who completed commented cards answered NO to the question “In your opinion are there always sufficient numbers of staff on duty?” The inspectors viewed the recruitment files of 4 staff and found them to contain all required information giving evidence of a thorough recruitment process. Two recently appointed staff were spoken with. Both were happy with the induction training that they had received and felt well supported in their new jobs. Staff have received training in health and safety issues such as manual handling, first aid and food hygiene. The majority of staff have now received in house training in the protection of vulnerable adults and short courses in the care of people who have a dementia. Some staff spoken to felt that they would benefit from further training in issues relating to dementia. It was noted that staff appraisal documentation contained information on training needs and a personal development learning style questionnaire. Hazelwell Lodge DS0000016068.V301353.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 36, 37 & 38. Overall quality in this outcome group is good. The home is effectively managed taking into account the views of service users and other interested parties. EVIDENCE: The registered manager of the home is Nicola Overd who was away at the time of the inspection. On the day of the inspection the home’s deputy was managing the home. One of the owners of the home was also present for part of the inspection. The deputy was extremely knowledgeable about the service users and staff and was professional in her attitude. Hazelwell Lodge DS0000016068.V301353.R01.S.doc Version 5.2 Page 22 All records requested were made available. With the exception of service user assessments, all records seen were comprehensive, well maintained and up to date. The inspectors viewed returned questionnaires, which had been sent out as part of the homes quality assurance. There were many positive comments and it was evident that any issues raised were being addressed. Minutes of staff meetings showed that the outcomes of CSCI inspections are shared with all staff and discussed in order to raise standards in the home. All staff receive annual staff appraisals and regular formal supervision. Records of supervision sessions seen showed that they cover a wide variety of issues including each member of staffs training needs and personal development. Measures are in place to ensure the health and safety of service users and staff. Two maintenance people are employed in the home. A fire log is maintained which shows alarms are tested on a weekly basis. Currently emergency lighting is tested quarterly by outside contractors. All staff have received training in fire safety. Lifting equipment in the home is regularly serviced. Call bells are tested monthly. Water temperatures taken in one communal bath was above the recommended level and this was raised with one of the maintenance people at the inspection. Up to date certificates of insurance and registration are displayed in the home. Hazelwell Lodge DS0000016068.V301353.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 2 2 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 3 X 3 X 2 STAFFING Standard No Score 27 1 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X 3 3 3 Hazelwell Lodge DS0000016068.V301353.R01.S.doc Version 5.2 Page 24 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 OP27 Regulation 18 (1) [a][b] Requirement The registered person must ensure that the home is adequately staffed by suitably qualified/experienced staff at all times. Sleep in staff must be identified on the duty rota. (This requirement has been carried over from the previous inspection.) All pre admission assessments must be comprehensive and give information about likes, dislikes and preferred routines. The registered person must ensure that care plans cover all areas of need as determined by comprehensive assessments. The registered person must produce an improvement plan, with dates, for the upgrading of the environment with particular regard to laundry facilities and upstairs bedrooms. A copy of this plan to be forwarded to CSCI. The registered person must ensure that suitable infection control measures are in place. DS0000016068.V301353.R01.S.doc Timescale for action 30/07/06 2 OP3 14(1)[a] 12(3) 15 (1) 12 (3) 23(2) 15/08/06 3 OP7 30/09/06 4 OP19 15/08/06 5 OP26 13 (3) 31/08/06 Hazelwell Lodge Version 5.2 Page 25 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 OP26 Good Practice Recommendations It is strongly recommended that a sluice room including a bedpan washer be installed following consultation with Somerset and Dorset Health Protection Unit. This recommendation will remain ongoing. The statement of purpose should be updated. The home should ensure that the service user guide is made available to all service users and/or their representatives. A risk assessment should be carried out on the garden at the rear of the property to determine whether or not it can be freely accessed by service users. All staff should have ongoing training and guidance in the care of people who have a dementia. Emergency lighting should be tested on a monthly basis. 2 OP1 3 4 5 OP19 OP30 OP38 Hazelwell Lodge DS0000016068.V301353.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 Hazelwell Lodge DS0000016068.V301353.R01.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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