Inspection on 08/06/07 for Hazelwood House Residential Home

This inspection was carried out on 8th June 2007.

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

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

Other inspections for this house

Hazelwood House Residential Home 09/08/06

Hazelwood House Residential Home 21/02/06

Hazelwood House Residential Home 10/08/05

Hazelwood House Residential Home 25/11/04

Hazelwood House Residential Home 15/06/04

Hazelwood House Residential Home 12/02/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Hazelwood House Residential Home 58-60 Beaufort Avenue Kenton Middlesex HA3 8PF Lead Inspector Judith Brindle Key Unannounced Inspection 8th June 2007 08:30 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 Hazelwood House Residential Home DS0000054194.V337925.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. Hazelwood House Residential Home DS0000054194.V337925.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hazelwood House Residential Home Address 58-60 Beaufort Avenue Kenton Middlesex HA3 8PF 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) 020 8907 7146 020 8907 5901 Mr Ramnarain Dyanan Sham Mr Ramnarain Dyanan Sham Care Home 15 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (0), Old age, of places not falling within any other category (15) Hazelwood House Residential Home DS0000054194.V337925.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th August 2006 Brief Description of the Service: Hazelwood House is a registered care home providing personal care and accommodation for a maximum of 15 older people aged over 65 years who have mental health needs. The home is located in a quiet residential road in Kenton. It is fairly close to shops, pubs and other community facilities. The home was originally 2 semi-detached houses. It has a passenger lift. The home has 11 bedrooms, of which five have ensuite facilities, and four bedrooms are shared. There are two bathrooms on the first floor, and a shower room on the ground floor. The home has gardens to the rear that are well maintained and accessible. Information/documentation about the service and the range of fees (£500£550) is accessible from the care home to residents and others. Additional costs are recorded in resident’s statement of terms and conditions, and in the statement of purpose. Hazelwood House Residential Home DS0000054194.V337925.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place throughout a day in June 2007. There were no vacancies at the time of the inspection. The inspector was pleased to meet and talk with the people living in the home, and with staff on duty. Staff were very helpful during the inspection, and supplied all documentation, and information requested by the inspector. The inspector also spoke with a community nurse and a visitor during the inspection. The registered manager/provider was present during the inspection. The inspection focussed on spending time talking with people living in the care home (thirteen residents were spoken too), and observing interaction between residents and staff. Documentation inspected included, resident’s care plans, residents’ financial records, risk assessments, staff training records, and some policies and procedures. The inspection included a tour of the premises. Assessment as to whether the requirements from the previous inspection had been met also took place during the inspection. 24 National Minimum Standards for adults, including Key Standards, were inspected during this inspection. The inspector thanks all the people living in the care home, visitors and the staff for their assistance in the inspection process. What the service does well: The care home has a very welcoming atmosphere. Residents live in a homely environment. People living in the home were positive about the care home and staff, and confirmed that they were happy living in the home. There is close liaison with healthcare professionals and other specialists as and when required/needed by the residents. Residents’ contact with relatives and others (as agreed by the residents) is fully supported and enabled by the care home. A caring, well trained, and competent staff team demonstrate knowledge, and understanding of the varied needs of people living in the care home. Hazelwood House Residential Home DS0000054194.V337925.R01.S.doc Version 5.2 Page 6 The home has a large well maintained garden. Residents spoke of enjoying this facility. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Hazelwood House Residential Home DS0000054194.V337925.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 Hazelwood House Residential Home DS0000054194.V337925.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 and 3 (6 is not applicable) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place for prospective service users to have the information that they need to make an informed choice about where to live. Arrangements are in place to ensure that residents have their needs assessed prior to moving into the care home. EVIDENCE: The statement of purpose and the service user guide documents include information about the service provided by the care home. The statement of purpose has been reviewed this year. The manager reported that all the people living in the care home had received a copy of the service user guide. The manager could review the format (i.e. pictorial format) of the service user guide with residents, to improve its accessibility to those who have difficulty in reading, communication needs, and who have English as a second language. Hazelwood House Residential Home DS0000054194.V337925.R01.S.doc Version 5.2 Page 9 The home has an admissions procedure. Care plans inspected recorded evidence that recently admitted residents had had their initial needs assessed. Assessment information from the funding authority was also documented. The manager confirmed that the initial assessment of a prospective resident needs was completed with them and with relatives/significant others (if applicable). Records informed me that residents had generally participated in an assessment of their needs. A resident confirmed that she had been asked questions about her needs prior to moving into the care home. Another resident spoke of her relative visiting the care home prior to her admission, and that she herself had been unable to visit the home due to being admitted straight from hospital. Residents have a month’s trial prior to being permanently admitted, which gives them the opportunity to decide if the home meets their needs. Hazelwood House Residential Home DS0000054194.V337925.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that resident’s individual personal and healthcare needs are met, but there could be further development in staff guidance to meet some specialist health needs. Arrangements are in place to ensure that the residents are respected and their right to privacy upheld. Medication is stored and administered safely. EVIDENCE: All the residents have a plan of care. The care plans were all inspected, and included recorded evidence of assessment of residents’ needs, including preferred name, personal care needs, health needs, physical care needs, mental health needs, and cultural needs. Individual goals and staff guidance to support residents in meeting their assessed needs were recorded. Some guidance in regard to a resident’s diabetic needs was not comprehensive, and needs further development to ensure that all staff have an understanding of Hazelwood House Residential Home DS0000054194.V337925.R01.S.doc Version 5.2 Page 11 how to meet these needs. This was discussed with the manager, who agreed to put this guidance in place. The care plans recorded evidence of being regularly reviewed. There was some evidence of residents being involved in the review of their care plan, but two of three care plans inspected did not record evidence of residents significant participation in their care plan i.e. signatures from the resident were not evident in several sections of the care plans, such as inventories of possessions, and the consent section in the care plans was not signed by all residents. Development of care plans into a more ‘person centred’ format was discussed with the manager. The manager should continue to further develop care plans into a more ‘person centred’ format with residents to ensure that people using the service experience the life the each person wants. Photographs of two residents (fairly new admissions) were not evident in their care plans. The manager spoke of awaiting relatives to bring in photographs. All care plans should include a photograph of the resident. Care plans inspected included moving and handling assessment, pressure sore assessment, and ‘nutrition screening assessment’. There is a prevention of pressure sores policy/procedure. The manager reported that there were no residents who have pressure sores. ‘Daily’ and night records are completed by staff in regard to the progress of each person living in the care home. The care plans included some evidence of risk assessment. These included risk assessment of falls, challenging behaviour, and bathing/showering. This guidance is reviewed monthly. Records confirmed that residents generally received showers not baths. A visitor confirmed this. There should be recorded evidence that baths are offered to residents unless that they have clearly stated in their care plan that they do not want a bath. Residents were very positive about the staff, and confirmed that their privacy was respected. Staff were observed to respect resident’s privacy during the inspection. Records and residents confirmed that people using the service have their health needs met. Appointments with the GP, optician, dentist, community nurse, chiropodist, were documented. A community nurse and a community psychiatric nurse visited residents during the inspection. Records confirmed that residents attended hospital appointments. The medication administration and storage systems were inspected. Medication is stored securely, and medication received from the pharmacist is checked and recorded by staff. Hazelwood House Residential Home DS0000054194.V337925.R01.S.doc Version 5.2 Page 12 Records and staff confirmed that staff have received medication training from the pharmacist. A staff member said that medication training and medication workshops were also included in a NVQ health and care college course that was attended by her. The manager should record the content of the ‘in house’ medication training, which is given to staff. This was discussed with the registered manager/provider. Medication administration record sheets confirmed that there were no gaps in recording. The registered manager should obtain an updated British National Formulary (BNF) from a pharmacist. This details medicines prescribed in the UK, with special reference to their uses, cautions, contra-indications, side effects, and dosage, and could be useful to all staff working in the care home. Hazelwood House Residential Home DS0000054194.V337925.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 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. Arrangements are in place to ensure that residents have the opportunity to participate in some activities, but there needs to be further development in the provision of daytime activities. The visiting arrangements are flexible and meet the needs of visitors and residents, so that residents have the opportunity to develop and maintain important relationships. Residents are supported to make choices. Meals provided are varied and nutritious. EVIDENCE: Records confirmed that residents do participate in some activities. These include watching television, reading the newspaper, listening to the radio, having regular manicures, and sitting out in the garden. The inspector was informed by staff and a resident that during the week a pianist visits the home twice providing music entertainment to residents. A resident spoke of enjoying this entertainment. Two residents spoke of sometimes going shopping in local Hazelwood House Residential Home DS0000054194.V337925.R01.S.doc Version 5.2 Page 14 shops and Harrow. One resident was observed to participate in a gardening activity. A resident spoke of obtaining books from a visiting library. There was no evidence of a planned group activity or of ‘one to one’ planned activities for residents during this inspection. Several residents were observed to sleep for long periods during the unannounced inspection. This was discussed with the manager. He spoke of the occasional day trip that take place during the summer months, and of a summer party and a Christmas party that takes place annually in the care home. Feedback from residents and a visitor during the inspection informed the inspector that there was a view that there were not enough activities, provided for (and with) residents. These could include walks outside the care home in the community, and regular ‘in house’ activities, including an opportunity to participate in a regular exercise session. The provision of activities was discussed with the manager. The registered manager/provider needs to ensure that people living in the care home are given the opportunity to be involved in meaningful daytime activities of their own choice, and according to their individual interests and capability. This was a previous inspection requirement. Residents spoke of receiving visitors in the home on a regular and flexible basis. Visitors (including healthcare professionals) spoke of visiting the care home at different times of the day, and spoke positively about the home. Staff were observed to offer residents choice during the inspection. Residents who kindly spoke with the inspector said that they were happy about the care and support that they received from staff. The menu was displayed and recorded a variety of wholesome and nutritious meals. A menu for Asian residents was recorded in Gujarati. The format of the menus could be improved to include pictures to ensure that it is more accessible for residents who have difficulty in reading. Choice was indicated on the menu, and staff gave examples of when a different meal was provided to residents such as a preference for sandwiches rather than the main meal. Residents were offered choice in regard to their meals. The lunch provided during the inspection was unhurried and residents reported that the meal was very pleasant, and well presented. A variety of condiments were offered to residents during meals. Asian residents received a lunch, which met their cultural needs, and spoke of enjoying the meal. Staff had knowledge and understanding of specific dietary needs of residents. A staff member explained how staff gained information about the preferred foods that residents enjoyed, particularly in regard to those with communication needs. Residents were offered frequent drinks and snacks, including fruit during the inspection. Care staff carry out the catering role in the home. Records confirmed that staff complete certified food and hygiene training. Hazelwood House Residential Home DS0000054194.V337925.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place for ensuring that complaints are taken seriously and handled objectively. Arrangements are in place to ensure that service users are protected from abuse, neglect and self-harm. EVIDENCE: The care home has a complaints procedure, which includes timescales in regard to responding to a complaint. This is documented in the service user guide. There were no complaints and/or concerns recorded in the ‘complaints register’. The registered person should examine ways (with people using the service) to improve the accessibility of the complaints procedure for those who have difficulty reading, and for those for whom English is not their first language, to help anyone living at, or involved with, the service to complain or communicate a concern. Records confirmed that residents have the opportunity to attend residents meetings. A resident spoke of being happy living in the home and that they would speak to a member of the care staff or relative if they had a concern/complaint. The registered person should continue to develop ways of ensuring that there is evidence that ‘concerns’ as well as complaints are welcomed and documented. Hazelwood House Residential Home DS0000054194.V337925.R01.S.doc Version 5.2 Page 16 A concern/complaint was expressed during the inspection. The registered person assured the inspector that this would be recorded and acted upon in accordance with the complaints procedure. The policies and procedures for Safeguarding Adults are available and give clear specific guidance for those using them. Staff working at the service know when incidents need external input and who to refer the incident to. Records and staff confirmed that they had received protection of vulnerable adults training. Staff and records informed the inspector that some staff had recently attended a protection of vulnerable adults training workshop. Hazelwood House Residential Home DS0000054194.V337925.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 19, 23 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment of the home is safe, homely and comfortable. The premises are suitable for the care home’s stated purpose. Residents bedrooms are individually personalised, meet their individual needs. The care home is clean, and odour free. EVIDENCE: The care home is located within a few minutes walk from local shops and bus public transport facilities. There is parking for several cars on the forecourt of the care home. The inspection included a tour of the premises. The care home is well maintained, homely, clean and airy. The living environment is appropriate for the particular lifestyle and needs of people living in the home. Houseplants, pictures and a fish tank are located in the communal sitting room of the home. Hazelwood House Residential Home DS0000054194.V337925.R01.S.doc Version 5.2 Page 18 Residents spoke of particularly enjoying the garden, and some were observed to sit out in the garden during the inspection. The garden is well maintained and contains a variety of shrubs and other flowering plants. There could be improvement in some aspects of the environment. There were some rooms named such as the bathrooms, and residents rooms, but the format could be developed i.e. pictures describing rooms could be displayed doors (for those who have difficulty reading and or specific communication needs) and possibly the painting of doors of some rooms in different colours, would improve orientation of the environment for some residents. This was discussed with the manager who spoke of having sought advice from specific charitable organisations for their advice. This is positive. All the communal chairs had ‘seat mats’ on them, which were unsightly. The need for these was discussed with the manager, who reported that they were not necessary and would be removed. Radiators in the home each have a protective covering. There were some portable fans and heaters located in the care home. These need to be risk assessed to ensure that they are safe, and of minimal risk to people living in the home are safe. Bedrooms inspected had some personal features, including photographs and pictures. Residents spoke of being happy with their bedrooms. Laundry facilities are located away from food storage, and food preparation areas. Hand washing facilities are located throughout the home. The staff toilet did not have soap. This needs to be accessible. Protective clothing was accessible to staff. Staff spoke of the flooring in the toilets in the home having been recently replaced. Staff complete cleaning duties in the home. Records confirmed that staff had received infection control training. Hazelwood House Residential Home DS0000054194.V337925.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 27,28 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff receive training to ensure that they are competent and skilled in regard to carrying out their roles and responsibilities. Arrangements are in place to ensure that residents are generally supported and protected by the care home’s recruitment policy and procedure. EVIDENCE: The staff rota was available for inspection. There were three care staff on duty, and the manager at the time of the inspection. There is a wake night staff and a ‘sleep in’ staff member on duty at night in the care home. The manager confirmed that staffing numbers are flexible in order to meet the changing needs of the residents. The review of staffing numbers should be carried out to ensure that staff are able to provide a choice of daytime activities to residents. The manager confirmed that all staff are permanent and work full time, and that agency staff is not presently used in the home. The care home has a recruitment procedure. Four staff personnel files were inspected. Two of these included appropriate required information and documentation. Two staff files did not include evidence of an application form Hazelwood House Residential Home DS0000054194.V337925.R01.S.doc Version 5.2 Page 20 having been completed, another staff file did not include evidence that references had been obtained, and one file included one reference only. The manager spoke of this documentation being located elsewhere. There needs to be evidence that required recruitment and selection procedures have been carried out as required for all staff. Staff spoke of having completed induction training. This is a comprehensive programme. A staff member said that on commencement of employment she observed senior staff assisting residents with their personal care needs, prior to carrying out that role herself. Staff spoke of feeling well prepared and confident in carrying out their roles following a programme of induction. Records confirmed that staff receive a staff code of conduct and a contract of terms and conditions. Records and staff confirmed that varied appropriate staff training takes place. This includes manual handling training, medication training, 1st Aid, fire awareness training, personal care training, and other training meeting the specialist health needs of residents. Staff spoke of having completed relevant NVQ care courses. The inspector was informed that three staff are in the process of completing NVQ level 3 having completed an NVQ level 2 in care. Several staff speak English as a second language, they spoke of the process of gaining more knowledge of English during their time working in the home, and of how they communicated with other staff to assist them when they had been unsure of what a resident had said. Staff were observed to communicate freely with residents during the inspection. People living in the home confirmed that staff understood them fully. Staff informed the inspector that a staff member spoke Gujarati. Residents were very positive about the care staff, and spoke of knowing them well and gave examples of particular caring actions taken by staff. A visitor spoke of staff ‘being a credit to residents’, and spoke of being satisfied with the care provided to a relative. Staff were observed to interact with residents in a sensitive and respectful manner. Staff spoke of receiving regular supervision. Records confirmed that staff appraisals are carried out. Hazelwood House Residential Home DS0000054194.V337925.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 31,33,35, 36, 37 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The registered manager/provider is qualified, competent and experienced to run the care home. Arrangements are in place to ensure that effective quality assurance and quality monitoring systems are in place to monitor and improve the quality of the service provision by the care home. Arrangements are in place to ensure that so far as reasonably practicable the health, safety and welfare of residents and staff is promoted and protected. EVIDENCE: Hazelwood House Residential Home DS0000054194.V337925.R01.S.doc Version 5.2 Page 22 The registered manager is also the owner of the care home. He has managed the home since 2003. Prior to this, for several years he managed another care home for older persons. He has achieved a NVQ level 4 Registered Manager’s Award qualification. The registered manager undertakes periodic training to update his skills and knowledge. He has a very much ‘hands on approach’ and assisted residents with meeting their care needs during the inspection. Residents spoke highly of the manager and it was evident that they knew him well. Records confirmed that the manager works in the care home most days. He spoke of monitoring closely the care provided by care staff to people using the service. Records informed the inspector that on occasions some staff have considered that his manner in regards to communication with them could be improved. This was discussed with the manager. He spoke of his aim in ensuring that all staff provide a quality service to residents, and agreed to review the manner in which he sometimes communicates with staff. The home has a quality assurance policy/procedure. Arrangements are in place to ensure that the quality of the service is monitored. The home has an annual development plan for 2005-06. An annual audit dated 2005 was available for inspection. The manager spoke of being in the process of completing a plan for 2006-07. The manager ensures that staff follow procedures and policies. Record keeping is of a generally a good standard. The manager spoke of ‘spot’ checks in the home to ensure that the practice reflects the home’s policies and procedures. A healthcare professional and a visitor spoke positively about the atmosphere and care provided in the home. A visitor spoke of staff being committed to giving residents quality care. The home has an equal opportunities policy/procedure. Staff and residents have the opportunity to attend and participate in staff meetings. Some questionnaires dated 2005 and 2006 in regard to residents and others views of the service were available for inspection. These were positive about the service provided. The manager confirmed that he would supply questionnaires to stakeholders (residents, relatives, healthcare professionals and others) this year. This should be carried out. People living in the care home receive varying levels of support in regards to the management of their finances. Two residents manage their own money; others have relatives that support them in the management of their money. Staff spoke of buying some items for some residents. Receipts were available for inspection. Some receipts did not record the items bought. Staff need to ensure that there is a clear record of what items were bought for residents, and individual inventories of resident’s clothes should be kept updated. The care home has health and safety policies and procedures, including an accident reporting procedure, and a manual handling procedure. Health and safety checks are carried out in the home. Fridge and freezer temperatures are monitored, and the passenger lift had recently received a safety check. Hazelwood House Residential Home DS0000054194.V337925.R01.S.doc Version 5.2 Page 23 Electrical and gas systems service checks were generally up to date. The gas system check was due in May 2007. The manager spoke of the plans that this check and the electrical portable appliance check be carried out. Required fire safety and fire drills checks take place. A fire risk assessment has been recently reviewed. Records confirmed that staff receive fire training. Fire safety guidelines are displayed in the home. The manager spoke of having recently spoken to the local fire service, and in response to this had ordered battery operated door opening systems. The employer’s liability insurance certificate was displayed and up to date. Hazelwood House Residential Home DS0000054194.V337925.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X 3 X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 3 X 3 Hazelwood House Residential Home DS0000054194.V337925.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 12, 13(1)(4) Requirement Some guidance in regard to a resident’s diabetic needs was not comprehensive, and needs development to ensure that all staff are competent in meeting this person’s needs. The registered person needs to ensure that all residents are offered activities everyday, which meet individual resident’s needs, and to have a system in place to ensure that activities recorded on the activity plan are offered to residents even when the activity staff member is not on duty Previous timescales 01/10/06 not met. Portable fans and heaters need to be risk assessed to ensure that they are safe, and of minimal risk to people living in the home are safe. There needs to be evidence that required recruitment and selection procedures have been carried out as required for all staff. DS0000054194.V337925.R01.S.doc Timescale for action 01/09/07 2 OP12 12, 16(m) 01/08/07 3 OP19 12,13(4) 01/08/07 4 OP29 19(1) 01/08/07 Hazelwood House Residential Home Version 5.2 Page 26 5 OP35 13(4) 6 OP38 23(20 Staff need to ensure that there is 01/08/07 at all times a clear record of what items were bought for residents. The manager needs to supply 01/08/07 the Commission for Social Care Inspection with evidence that a gas system safety check has been carried out. 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 OP1 Good Practice Recommendations The manager could review the format (i.e. pictorial format) of the service user guide with residents to improve its accessibility to those who have difficulty in reading, have communication needs, and who have English as a second language. • The manager should continue to further develop care plans into a more ‘person centred’ format with residents. • There should be evidence that baths are offered to residents unless that they have clearly stated in their care plans that they do not want a bath. • All care plans should include a photograph of the resident. • The manager should record the content of the ‘in house’ medication training, which is given to staff. • The registered manager should obtain an updated British National Formulary (BNF) from a pharmacist. The registered manager could offer people living in the home exercise sessions on a daily basis to residents. The format of the menu could be improved to include pictures to ensure that it is more accessible for residents who have difficulty in reading. • The registered person should examine ways (with people using the service) to improve the accessibility of the complaints procedure for those who have difficulty reading, and for those for whom English is not their first language. DS0000054194.V337925.R01.S.doc Version 5.2 Page 27 2 OP7 3 OP9 4 5 6 OP12 OP15 OP16 Hazelwood House Residential Home 7 8 OP19 OP24 9 10 11 12 13 OP27 OP31 OP33 OP33 OP37 The registered person should continue to develop ways of ensuring that ‘concerns’ as well as complaints are welcomed and documented. ‘Seat mats’ should be removed from the communal chairs unless assessed as necessary. The format for identifying rooms in the home could be developed i.e. pictures describing rooms displayed on doors, and possibly painting doors in different colours, so as to improve orientation for those living in the home. The review of staffing numbers should be carried out to ensure that staff are able to provide a choice of activities to residents. The manager should continue to review the manner in which he sometimes communicates with staff. The manager should complete an up to date annual development plan. The manager should supply questionnaires to stakeholders (residents, relatives, healthcare professionals and others) in 2007. Inventories of residents’ possessions should be kept up to date. • Hazelwood House Residential Home DS0000054194.V337925.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Harrow Area Office 4th Floor, Aspect Gate 166 College Road Harrow London HA1 1BH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Hazelwood House Residential Home DS0000054194.V337925.R01.S.doc Version 5.2 Page 29 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!