Inspection on 31/05/06 for Hazelwood Care Home

This inspection was carried out on 31st May 2006.

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

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

Other inspections for this house

Hazelwood Care Home 15/05/07

Hazelwood Care Home 07/12/05

Hazelwood Care Home 27/07/05

Hazelwood Care Home 31/01/05

Hazelwood Care Home 21/06/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Hazlewood Care Home Skeavingtons Lane Cotmanhay Ilkeston Derbyshire DE7 8SW Lead Inspector Claire Williams Unannounced Inspection 31st May 2006 11:15 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 Hazlewood Care Home DS0000035716.V297778.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. Hazlewood Care Home DS0000035716.V297778.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hazlewood Care Home Address Skeavingtons Lane Cotmanhay Ilkeston Derbyshire DE7 8SW 0115 9098100 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) Derbyshire County Council Beryl Ann Ryder Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Hazlewood Care Home DS0000035716.V297778.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th December 2005 Brief Description of the Service: Hazelwood is a care home currently registered to provide personal care and accommodation for 30 older people. The single-storey home is owned by Derbyshire County Council and is situated in the village of Cotmanhay on the outskirts of the town of Ilkeston. The Home comprises of separate wings, each with a lounge and dining area. There is also a larger communal lounge area situated near to the main entrance and the administration offices. All bedrooms are single occupancy. There is separate bath/shower and toilet provision (no bedrooms are equipped with en-suite facilities). The Home has a hairdressing salon. Support services include General Practitioner, district nurse, chiropodist, dentist and optician. The home has recently reduced the number of people occupied in the home to 30 in order to facilitate a rehabilitation centre, which has been developed using one of the wings of the home. This service is operated independently of the home. The fees for the home commence from £289.70 per week. Hazlewood Care Home DS0000035716.V297778.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over an eight hour period. The inspection involved assessing key areas as identified by the CSCI. The inspector spoke with 1 relative and 8 residents and examined four files using the Case tracking methodology. A tour of the building was undertaken and time was spent observing residents and staff interaction. The inspector spoke with 2 staff members and examined three files. The Registered Manager is off long term sick and the deputy manager is acting up, into her role in her absence. She was present throughout the inspection and provided assistance and information. A number of records were examined, including risk assessments and care plans, and health and safety documentation. An assessment was also made of the progress by the registered persons to address the requirements made at previous inspections. Following discussions with the people living at the home and the staff and management team it was agreed that for the purpose of this report those living here would be collectively termed as “residents”. What the service does well: What has improved since the last inspection? The home has now completed all of the work required to meet the requirements from the Environment Health Officer report. The call systems are routinely checked and the staff respond to all calls as quickly as possible. Verbal confirmation was received from the acting manager that the night staff had received Fire training twice yearly but the records still did not reflect this. The staff ensure that personal toiletries are not left in communal areas. The cook ensures that all food placed in the fridge is labelled and dated. Hazlewood Care Home DS0000035716.V297778.R01.S.doc Version 5.2 Page 6 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. Hazlewood Care Home DS0000035716.V297778.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hazlewood Care Home DS0000035716.V297778.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5 (Standard 6 not applicable) Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective service users and relatives are provided with the information they need to help them make decisions about the home. The needs of new residents were assessed and it was assured that their needs could be met. EVIDENCE: There was a statement of purpose and service user guide available at the home. The inspector was informed that both documents are to be reviewed so that they reflect the current situation at the home and include the changes made to the number of people occupied and the environmental changes due to the recent refurbishment and development of the rehabilitation unit. The acting manager also briefly discussed the contract/ terms and conditions and the inspector had a look at this document. Although it did contain the required information the fees were incorrect and it did not include information about what provisions the residents are expected to pay for. All of the residents living at the home have been referred by a Care manager and therefore everyone had a pre-admission assessment completed. The Hazlewood Care Home DS0000035716.V297778.R01.S.doc Version 5.2 Page 9 acting manager confirmed that she does routinely visit all perspective residents and undertakes her own assessment in order to ensure that the home is able to meet the individual’s needs. However the acting manager does not have access to a pre-admission assessment in order to undertake this assessment and instead writes notes of the visits. It would be beneficial for the acting manager to have a recording tool for this purpose to ensure she obtains the required information. This assessment could then be used on individuals who are self-funding and do not have a Care manager. The assessments completed by the Care manager are the new FACE single assessments tools. The inspector and the acting manager discussed some of the problems encountered with accessing and using these documents which are competed electronically and then sent to the home, but sometimes the documents are read only and therefore this limits the use of the assessment and prevents the residents from having access to them. In evident through the discussions with residents that trial visits are encouraged. Residents also use the provision of short-term care as a way of “test driving the home “ before making a decision about moving in permanently. Hazlewood Care Home DS0000035716.V297778.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Resident’s health, personal and social care needs were not clearly set out in their personal care plans. The medication practices require improving in order to safeguard staff and residents. Residents felt respected by the staff team, and confirmed that their privacy and dignity is upheld. EVIDENCE: The inspector examined four residents’ files, one of these files was for a resident who was admitted as short-term care but had made the decision to remain on a permanent basis. The residents had two files containing their information, but there did not seem to be a system in place in order to be able to access the information. Documents were filed randomly within the files and each file contained old information making it difficult for the inspector to ascertain which care plan was the most current one. Three out of the four files contained a night and day personal service plan. In one file the night plan contradicted with that for the day in relation to the support required. The resident who had become permanent had only a night care plan within the file as a full care plan for the day had not yet been completed. Information in relation to likes and dislikes and social hobbies was not available in all of the Hazlewood Care Home DS0000035716.V297778.R01.S.doc Version 5.2 Page 11 files. There was evidence that the care plans had been reviewed but as mentioned due to their being more than one care plan in the files and more than one date on the plan it was confusing as to which plan was the most current. There was limited evidence to support that all of the residents had been involved in the development of their plan. There was some evidence in two of the files of month ending reports. The inspector did advise that these reports should link in with the care plan as well as being an overview on the individual’s well being. All of the files contained the required risk assessments apart from a falls assessment. One file contained a moving and handling assessment that was out of date, the inspector was informed that this had been recently reviewed but the management team was unable to find the updated copy. Although some records had a date and statement that they had been reviewed there was no explanation as to the outcome of the review undertaken. Daily care recordings were made on a regular basis reflecting the individual’s well being. The medication practices and records were examined for those individuals case tracked. Two people did not countersign handwritten medication instructions, and the inspector noted some gaps on the Medication Administration records (Mar chart) that did not have a recorded explanation. Controlled drugs were stored appropriately and the acting manager informed the inspector that one tablet was not accounted for and this had been reported and was being investigated. The temperature of the medication fridge was recorded but there were some gaps in these recordings and the maximum temperature exceeded the required temperature of 8. The inspector advised the acting manager to consult their local pharmacy about this and then take the required action. The inspector was informed that the managers who administer the medication had previously undertaken training, however an assessment to confirm their competency in this area, had not been developed or completed. Residents had signed declarations stating their choice on the support required in respect of their medication. If residents stated they wanted to self-medicate an assessment of there ability to do this safely was not available. Residents spoke very highly about the quality of the care they received. All felt their needs were “more than met” by the staff team and comments made included, “its great here, we are well looked after”, “the staff and the care is exceptional”. Staff were observed knocking on individuals doors before entering and were respectful to residents when undertaking tasks. All residents felt that there privacy, and dignity was respected and that personal care tasks were completed in a sensitive manner. Hazlewood Care Home DS0000035716.V297778.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s felt that the lifestyle experienced in the home was in accordance with their preferences. Visitors to the home were welcomed and contact encouraged. Residents enjoyed the meals provided. EVIDENCE: Residents spoken with stated that the routines within the home were flexible and that they could choose how they wished to spend there day, and this was respected. There was information displayed about a trip organised for Skegness and some residents informed the inspector that they were looking forward to this. The inspector did not observe any activities being facilitated during the day, however music was played in one of the lounge areas. One resident stated that they preferred to go out on trips, and enjoyed this more than in house activities. There was limited information within individuals files on their interests and favourite past times, and individuals preferred routines. The inspector did not note any information displayed about the provision of inhouse activities. The inspector was informed that a library is to be developed in one of the lounge areas The inspector spoke with a visitor who visited the home on a regular basis. Positive comments were made about the quality and the consistency of the Hazlewood Care Home DS0000035716.V297778.R01.S.doc Version 5.2 Page 13 care their relative received. The visitor felt very welcomed within the home and commented on how supportive the staff and the management team always were. Comments were made on how the care delivered was “excellent”, and the routines “were flexible” and that the staff team were “very responsive to individuals needs”. Residents informed the inspector that they were consulted regularly about the running of the home, and confirmed that they exercised choice and control over their lives. The inspector joined the residents for their lunchtime meal. Although menus were provided in the lounge areas, the menu sheets for that day was incorrect due to amendments to the master menu in the kitchen. Residents stated that they are informed of the choices of food at the beginning of the day and then make their choices. It was evident from the observations of the meal that individuals had a meal that suited their preferences and choices were provided. The meal was relaxed and all commented on how nice the food “always was”. One resident stated that “the food is always good here, and the cook listens which is important”. A brief tour of the kitchen was undertaken and both the cook and the acting manager confirmed that all recommendations made by the Environmental Health Officer had been completed. The inspector examined the menus, and noted that occasional the same meal option was available within the same week. All food was stored appropriately and fridge temperatures were recorded although there were gaps when the cook was off duty. The home has recruited another part time cook and are awaiting for all of the recruitment checks to be completed. The inspector gave the head cook a copy of the publication devised by the CSCI on “improving meals for older people in care homes” which was devised following consultation with older people. Hazlewood Care Home DS0000035716.V297778.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents felt that their complaints and concerns were listened to and acted upon. Staff had a good awareness of their responsibilities in safeguarding adult’s procedures from abuse. EVIDENCE: A complaints system is in place and displayed around the home. Residents were confident about how to complain and that concerns would be listened to and acted upon. Residents spoken to emphasised that they had no complaints. The acting manager was informed that one procedure displayed contained the previous title for the CSCI and advised that this should be amended. The inspector was informed that no complaints have been received since the previous inspection. The home has received 6 cards complimenting and thanking the home on the standard and quality of the care provided. Comments included the following: “thank you for high level of care which enhancing quality of life”, “thank you for the care and attention”, and “the care provided is wonderful”. The acting manager confirmed to the inspector that a copy of the Derbyshire adult protection protocols was in place, and that all staff had received training in this area. It was evident from the discussions held with the staff team of their awareness of their responsibilities to protect residents and report any incidents observed. The inspector was informed that no incidents have occurred since the previous inspection. Hazlewood Care Home DS0000035716.V297778.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25, and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was well maintained and decorated and is suitable for its stated purpose, providing a comfortable, and homely environment for residents to enjoy. EVIDENCE: The home has recently had a major refurbishment completed, in order to upgrade the home and to section of the wing that has been redeveloped to become a rehabilitation unit. All areas of the home were well decorated with soft furnishings creating a comfortable and homely environment. The home provides two small lounges and one larger lounge area for the residents to use. A lot of hard work has been undertaken to ensure all residents were consulted about all of the changes and included in the decision making processes about the colour schemes. All areas viewed were clean and tidy and the inspector did not note any odours within the home. Hazlewood Care Home DS0000035716.V297778.R01.S.doc Version 5.2 Page 16 The inspector was invited to view some of the resident’s bedrooms, which were well decorated and personalised reflecting individuals preferences. Residents had access to lockable storage although one resident did not have a key. Some work has been done to the garden and patio areas, but more is required to make the grounds tidy and the lawn areas needed to be cut. Hazlewood Care Home DS0000035716.V297778.R01.S.doc Version 5.2 Page 17 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, and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Resident’s needs are met by a trained and competent workforce. Residents are protected by the homes recruitment procedures. EVIDENCE: The residents stated that they felt the staffing levels were adequate to meet their needs. The staff team commented that they were able to ensure that all residents were supported accordingly but at times due to the increasing dependency of residents they were very busy especially during the morning shift and comments were made that “its the paperwork that suffers”. The inspector was informed that usually there are three staff members on duty during the morning shift and two during the evening shift. However the inspector was informed that there currently are at least 8 residents that require the support of two staff members which means at times during the evening shift there is no staff on the floor if they are supporting an individual who is dependant. Therefore the management team need to ensure that adequate staffing levels are maintained depending upon the needs of the individuals currently living in the home. All residents spoke highly of the staff team and “how hard they work to look after everyone’s needs”. From observations the staff team had a good knowledge of the residents needs and they worked well together as a team. Hazlewood Care Home DS0000035716.V297778.R01.S.doc Version 5.2 Page 18 The staff commented that the managers do assist when the need arises, in particular during the peak times during a day. The inspector examined four staff files and majority of the information was available. One file for a new member of staff whom had recently commenced employment, had very little information contained within it. The inspector was informed that all of the records of the checks would be with the Human Resource department. It was advised that if they are to be stored centrally then the home must obtain evidence to support that all of the required checks have been undertaken. The inspector noted that although the application form requests a full employment history, if this is not provided the gaps are not then explored. The acting manager had organised interviews for the following weeks, and the inspector advised that she discuss the gaps in the employment record at the forthcoming interview for a potential new employee. The staff members spoken to confirmed that they had undertaken all of the mandatory training and commented on the positive training opportunities provided. There are currently 11 staff members who have completed the National Vocational Qualification (NVQ) level 2 and three staff have now started their level 3. Hazlewood Care Home DS0000035716.V297778.R01.S.doc Version 5.2 Page 19 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, and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed to ensure that all residents have a good deliver of care that meets there needs. Resident’s finances are safeguarded by clear and effective systems that are in place. EVIDENCE: The permanent manger is currently off on long term sick and the deputy manager is currently acting up into this role. Both the residents and staff members spoke positively about the acting manager and commented on how approachable and supportive she is. All of the management team have achieved a formal qualification. Staff in discussions confirmed access to regular supervisions and team meetings, and confirmed that the management team listen and are responsive to their requests. Hazlewood Care Home DS0000035716.V297778.R01.S.doc Version 5.2 Page 20 The inspector examined the system for managing resident’s finances. All of the money was held separately, and receipts obtained for the transactions made. The financial management and the records were found to be satisfactory. The management regularly consults residents and ongoing consultation has been maintained concerning the recent refurbishment. Residents have access to committee and amenities meetings, and receive an annual quality assurance questionnaire from the provider in order to obtain their feedback. A recent survey has been completed but the results have not been displayed due to some amendments being required to the report. The acting manager informed the inspector that all of the required health and safety checks were undertaken to ensure the building was safe. Although it was confirmed that a delegate from the provider does visit the home and examined the systems in the place, there was no records at the home of these visits for the inspector to examine. Hazlewood Care Home DS0000035716.V297778.R01.S.doc Version 5.2 Page 21 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 3 2 3 3 N/a 3HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 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 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Hazlewood Care Home DS0000035716.V297778.R01.S.doc Version 5.2 Page 22 Yes Are there any outstanding requirements from the last inspection? 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) (a) Requirement The Registered manager must have access to a pre-admission assessment that includes all of the required areas as specified in the National Minimum Standards. All residents must have a detailed care plan identifying their support needs and how these should be met. This plan must be reviewed and the outcome recorded of any changes to the deliver of care. The moving and handling risk assessments must be reviewed at least annually or when needs change. All residents must have a falls assessment completed. Two people must countersign handwritten medication instructions. The Mar Chart must be signed or an appropriate code recorded following the administration of medication. Timescale for action 01/09/06 2. OP7 15 01/08/06 3. OP8 12 (1) (a) 01/09/06 4. OP9 13 01/09/06 Hazlewood Care Home DS0000035716.V297778.R01.S.doc Version 5.2 Page 23 Staff must sign or use the relevant code on the Mar chart for all prescribed creams and ointments that require to be applied daily. The temperature of the medication fridge must be recorded on a daily basis. A medication competency assessment must be devised and completed on all staff that administers medication. A delegate of the provider must 01/08/06 undertake monthly visits in accordance with this regulation and produce a comprehensive and detailed report of the findings, which is stored at the home. (Requirement repeated from the last inspection report) The staff files must evidence all 01/09/06 of the training achieved in particular mandatory training and that night staff have received fire training twice yearly 5. OP33 26 6 OP38 23 (4) (d) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP1 OP2 OP7 Good Practice Recommendations The Statement of purpose and Service user guide should be updated to reflect the changes to the environment and the number of people the home is registered for. The contract / terms and conditions should be updated to include all of the required information. It would be beneficial if the residents care files were organised to make it easier to access important information. It should be made clear which care plan is the DS0000035716.V297778.R01.S.doc Version 5.2 Page 24 Hazlewood Care Home 4. 5. 6 7 OP7 OP9 OP9 OP15 8 9 10 OP16 OP21 OP29 most up to date plan for residents. Information about individuals likes and dislikes, and hobbies should be recorded as apart of their social care plan and food preferences. The local pharmacy should be consulted about the maximum temperature of the medication fridge to ensure safe storage of medication. A medication risk assessment should be undertaken to assess individuals ability to self medicate, part of which should include that medicines are kept safely. The menus should be reviewed to ensure residents receive a varied diet. The menus displayed should be amended to reflect changes to the master copy. The temperature of the fridges and freezers should be recorded twice daily. The complaints procedures displayed should reflect the current name of the inspection unit. Residents would benefit from having the toilet doors repainted, and the garden areas tidied. Confirmation that all of the required staff records are located at the human resource department should be placed on all staff files. Hazlewood Care Home DS0000035716.V297778.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Hazlewood Care Home DS0000035716.V297778.R01.S.doc Version 5.2 Page 26 - 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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