Inspection on 07/12/05 for Hazelwood Care Home

This inspection was carried out on 7th December 2005.

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 31/05/06

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 Anthony Barker Unannounced Inspection 7th December 2005 09:35 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.V267271.R01.S.doc Version 5.0 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.V267271.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Hazlewood Care Home Address Skeavingtons Lane Cotmanhay Ilkeston Derbyshire DE7 8SW 01629 580000 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 37 Category(ies) of Old age, not falling within any other category registration, with number (37) of places Hazlewood Care Home DS0000035716.V267271.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th July 2005 Brief Description of the Service: Hazelwood is a care home currently registered to provide personal care and accommodation for 37 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. Community psychiatric nurses, occupational therapists, physiotherapists and dietician are accessed as required. Staff training takes place to inform and enable staff to care for service users appropriately. Hazlewood Care Home DS0000035716.V267271.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The time spent on this inspection was 4.25 hours and was a routine unannounced inspection. The last inspection took place in July 2005 and was unannounced. Two residents and the Relief Deputy Manager were spoken to, records were inspected and there was a tour of the premises. One resident was ‘case tracked’ in order to assess the services provided from their perspective. The focus of this inspection was on progress made on the requirements and recommendations made, and those standards not assessed, at the last inspection. What the service does well: What has improved since the last inspection? What they could do better: Staff must respect the privacy and dignity of residents by always knocking on bedrooms doors before entering. The requirements from the latest Environmental Health Officer inspection report must be met. The registered person must ensure that staff respond to activation of the emergency call system with due attention. All staff must be provided with fire training at least Hazlewood Care Home DS0000035716.V267271.R01.S.doc Version 5.0 Page 6 annually, and night staff at least twice a year. All records, required to be kept, must be kept up to date. The monthly written reports on the conduct of the Home must be comprehensive and detailed. Personal toiletries must not be left in bathrooms, so as to prevent the spread of infection. Food stored in freezers must be labelled with descriptions and dates. 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.V267271.R01.S.doc Version 5.0 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.V267271.R01.S.doc Version 5.0 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 Prospective residents have the information they need to make an informed choice about where to live. Each resident had a written contract/statement of terms and conditions with the Home. EVIDENCE: The Home’s Statement of Purpose and Service Users’ Guide were satisfactory except that the latter did not contain residents’ views of the Home. The Service Users’ Guide had not been reviewed since April 2004. The statement of terms and conditions/contract provided to residents was satisfactory. Hazlewood Care Home DS0000035716.V267271.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 & 10 Residents’ health, personal and social care needs were being set out in comprehensive individual plans of care. Residents reported that they felt they were treated with care and respect, although it was noted during the inspection that their need for privacy and dignity was not being consistently met. EVIDENCE: The Personal Service Plan (Care Plan) of the resident who was case tracked was comprehensive. There was evidence of assessments being followed through. There was also evidence of managers monitoring care plans monthly and evidence of this was seen on monthly ‘log endings’. The daily logs were often worded very generally and were not particularly meaningful. Entries were made three times each day. Also, log entries tended not to link with care plan objectives. These issues were discussed with the Relief Deputy Manager. Recorded risk assessments had improved. The ones examined had been reviewed regularly with signatures and dates as well as recorded evidence of management monitoring. They covered a range of potential risk situations. During this inspection a resident fell and staff responded with care and sensitivity. Other aspects of standard 8 were not assessed on this occasion. Hazlewood Care Home DS0000035716.V267271.R01.S.doc Version 5.0 Page 10 The standard of recording of administered medicines was satisfactory. However, the documented agreement for self-administration of medicines had not been reviewed and in one file examined both the options – for the resident to retain possession and for staff to take full charge of medicines – were deleted. Other aspects of standard 9 were not assessed on this occasion. Comments from one resident spoken to, included, “On the whole we’re well looked after” and “staff are very helpful”. It was noted that music being played was age-appropriate. Staff were most welcoming. There was an attractive and private pay-phone area off a corridor. One member of care staff was seen to enter a resident’s bedroom without knocking on the door. The resident was in the room at the time. This observation was shared with the member of staff concerned and with the Relief Deputy Manager. Hazlewood Care Home DS0000035716.V267271.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 Residents were benefiting from a good range of recreational pursuits that satisfied their interests and needs. EVIDENCE: The Home was providing a good range of activities for residents both within and outside the Home. A photo-board in the entrance hall displayed images from past outings. The Christmas activities list was on display with five events recorded. Residents commented about the good quality of meals provided. Other aspects of standard 15 were not assessed on this occasion. Hazlewood Care Home DS0000035716.V267271.R01.S.doc Version 5.0 Page 12 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 Residents were confident that any complaints they made would be listened to, taken seriously and acted upon. EVIDENCE: The Home’s complaints procedure was displayed in the entrance hall. It included the name, address and telephone number of the Commission, the timescale within which complaints are responded to and made it clear that complaints can be made to the Commission at any stage. Residents made it clear, at this inspection, that when they expressed items of concern to staff they felt listened to and action was taken. The Home had a written procedure for responding to the suspicion of abuse which included action to be taken by the person in charge. Staff had received training with respect to dealing with verbal and/or physical aggression. Other aspects of standard 18 were not assessed on this occasion. Hazlewood Care Home DS0000035716.V267271.R01.S.doc Version 5.0 Page 13 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, 22, 24 & 25 Residents were starting to benefit from significant improvements to the Home’s environment, specialist equipment, heating and lighting. EVIDENCE: Major refurbishment of the premises was well underway at the time of this inspection – two of the three wings had been refurbished. The works were due to be completed in January 2006. Tarmac paths were being laid around the premises to allow safe use by residents. New PVC windows and doors were being fitted. The kitchen was being re-plastered and decorated. The letter, detailing the recommendations from the Environmental Health Officer’s last visit, was not available so it was not possible to ascertain whether all these recommendations had been met. However, the Relief Deputy Manager pointed out new fly screens in the kitchen and said that extractor fans had been cleaned and several other matters of hygiene in the kitchen had been addressed. A new disabled toilet was being created and a new bath fitted. Other aspects of standard 21 were not assessed on this occasion. Hazlewood Care Home DS0000035716.V267271.R01.S.doc Version 5.0 Page 14 Bathrooms were being redecorated and baths moved for easier hoist and wheelchair access. A new electric hoist had been installed in one bathroom. There was easier wheelchair access from the front and rear of the premises – from an improved front entrance and solid-looking ramps with substantial hand rails. An emergency call system was in place but one resident said that she had waited 30 minutes for staff to arrive following her activating the call point. All bedrooms were being re-fitted, redecorated and refurnished. A good range of facilities were seen in those bedrooms upgraded as part of the current building work. The Relief Deputy Manager said that residents had been involved in choosing wallpaper and soft furnishings for their room. All radiators had been upgraded as part of the current building work. It was noted that, of those seen, all were readily controllable by residents. All the Home’s lighting had been upgraded and was most satisfactory. Water safety checks and checks for risk of Legionnella were up to date. The work surface area in the laundry had been increased as part of the current building work. Policies and procedures for the control of infection were available. However, scheduled infection control training for staff had not been initiated, although the Relief Deputy Manager said plans for this were in hand. Other aspects of standard 26 were not assessed on this occasion. Hazlewood Care Home DS0000035716.V267271.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28 & 30 Residents were in the safe hands of a well-qualified and mainly well-trained group of staff. However, residents were potentially at risk from night staff inadequately trained in fire precautions. EVIDENCE: 93 of staff had achieved a National Vocational Qualification (NVQ) at level 2 at least. Each member of staff had a training record sheet that included details of updates needed. These records were satisfactory and showed that staff were undertaking mandatory training in First Aid, Basic Food Hygiene and Moving and Handling. However, in the Fire Training record it was noted that two members of night staff had not undertaken a fire training session since, respectively, July 2003 and April 2004. There was a recorded review of staff training but this was not up to date. Hazlewood Care Home DS0000035716.V267271.R01.S.doc Version 5.0 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35 & 38 The Home’s quality assurance system was not fully benefiting residents. Residents’ financial interests were being safeguarded. The safety and welfare of residents was not being completely protected. EVIDENCE: Monthly Monitoring Survey forms were seen. These were a record of monthly visits by external managers on behalf of the registered provider. However, these forms were very brief and only addressed feedback from newly admitted residents. There was no record of any visits since May 2005. A previously used Monthly Unannounced Visit form was more detailed but none were available since March 2003. There was evidence of managers monitoring staff recording practices. Two residents who were spoken to during this inspection both said that they were not aware of any residents’ meetings being held. One said, “They would be useful and give us opportunity to have a say”. The Relief Deputy Manager said that one meeting had been held since April 2005 – to Hazlewood Care Home DS0000035716.V267271.R01.S.doc Version 5.0 Page 17 inform residents of the impending building work. However, regular residents’ meetings were not being held as part of a quality assurance system. The Relief Deputy Manager was observed handing personal money to a resident following a request. The resident countersigned the manager’s signature and she then double-checked the running balance. A good system was in place for recording the transactions of residents’ money and ensuring its security. Product Data Sheets, as required by COSHH, were being provided in the staff room where staff had easy access to them, ie. they were close to where cleaning materials were stored. The Relief Deputy Manager said that all staff were familiar with their use. A resident’s personal shampoo and deodorant were found in one bathroom. These were removed by the Relief Deputy Manager. Foodstuff in refrigerators were being kept covered. The kitchen freezer was found to contain chicken pieces and peas that had not been labelled with a description or date. All other food hygiene practices were satisfactory and all maintenance checks were up to date. Hazlewood Care Home DS0000035716.V267271.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 X 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 2 X X 2 X 3 3 X STAFFING Standard No Score 27 X 28 3 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 X X 2 Hazlewood Care Home DS0000035716.V267271.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP10 Regulation 12(4)(a) Requirement Staff must respect the privacy and dignity of residents by always knocking on bedrooms doors, and waiting a reasonable time for a response, before entering. The requirements from the latest Environmental Health Officer inspection report must be met. (Previous timescale was 31/10/05) The registered person must ensure that staff respond to activation of the emergency call system with due attention. The registered person must ensure that all staff are provided with fire training at least annually, and night staff at least twice a year. All records, required to be kept, must be kept up to date. This includes records of training undertaken. The monthly written reports on the conduct of the care home must be comprehensive and detailed. (Previous timescale was 30/09/05) DS0000035716.V267271.R01.S.doc Timescale for action 01/02/06 2. OP19 16 (2), 23 (2) 01/03/06 3. OP22 13(4)(c) 01/02/06 4. OP30 23(4)(d) 01/03/06 5. OP30 17(3)(a) Sch4.6(g) 26 01/02/06 6. OP33 01/02/06 Hazlewood Care Home Version 5.0 Page 20 7. 8. OP38 OP38 13(3) 16(2)(j) Personal toiletries must not be left in bathrooms, so as to prevent the spread of infection. Food stored in freezers must be labelled with descriptions and dates. 01/02/06 01/02/06 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 OP7 OP9 Good Practice Recommendations The Service Users’ Guide should be reviewed and contain residents’ views of the Home. (This recommendation was from an inspection dated 31/01/05) Logs entries should be meaningful and link with care plan objectives or reflect new matters/changes. They do not have to be recorded daily. The system of assessment and documenting the arrangements for self-administration of medicines should be reviewed to provide a more detailed outcome from the assessments. (This recommendation was from an inspection dated 27/07/05) Formalised training for staff on infection control measures should be scheduled at regular intervals, as per other safe working practices training. (This recommendation was from an inspection dated 27/07/05) The Home’s quality assurance system should provide for consultation with residents through regular residents meetings. 4. OP26 5. OP33 Hazlewood Care Home DS0000035716.V267271.R01.S.doc Version 5.0 Page 21 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.V267271.R01.S.doc Version 5.0 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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