Inspection on 09/08/06 for Hazelwood House Residential Home

This inspection was carried out on 9th August 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Hazelwood House Residential Home 08/06/07

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 9th August 2006 09:00 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.V306381.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.V306381.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 7146 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.V306381.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st February 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 with mental disorder. The home is located in a quiet residential road in Kenton. It is fairly close to shops, pubs and other community facilities in Kenton. The home was originally 2 semi-detached houses. It has a passenger lift. The home offers a mixture of shared and single bedrooms. Most have en-suite facilities. The home has gardens to the rear that are well maintained and accessible. Information/documentation about the service and the range of fees (£450-500) 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.V306381.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 during a day in August 2006. The inspector was pleased to speak to most of the residents during the inspection. There was one vacancy at the time of the inspection. The purpose of the inspection was to spend time with the residents, assess key National Minimum Standards, and to follow up and assess as to whether requirements and recommendations from the previous inspection had been met. The inspection included a tour of the premises, and inspection of resident’s care plans, staff personnel files, medication storage and administration systems, and inspection of a variety of other records. The inspector also spent a significant part of the inspection talking with residents, and staff, and observing interaction between residents and staff. A visitor also kindly spoke with the inspector. The registered manager was present during the inspection. Staff kindly provided all the information, and documentation requested by the inspector during the inspection. The inspector thanks all the residents and staff, and others, for their participation in the inspection process. 22 National Minimum Standards including key Standards were assessed during this key inspection. What the service does well: What has improved since the last inspection? Hazelwood House Residential Home DS0000054194.V306381.R01.S.doc Version 5.2 Page 6 The inspection requirements from the previous inspection were judged to have been met. Staff training including NVQ training has continued to be developed; several staff have completed or were in the process of completing NVQ care courses. 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. Hazelwood House Residential Home DS0000054194.V306381.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.V306381.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): Standard 1, 3 (Standard 6 is not applicable) Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. Documentation about the service is accessible to residents. Arrangements are in place to ensure that residents have their needs assessed prior to moving into the care home. Information in regard to the service is accessible to residents and prospective residents and others. EVIDENCE: The home has a statement of purpose and a service user guide. Documentation about the service is accessible to residents. Service user guides were seen in several bedrooms inspected. The care home has an admissions policy/procedure. The care plans inspected (two of recently admitted residents) recorded evidence of an initial assessment and some further assessment information and documentation. The registered manager spoke of the assessment process, which generally includes a referral (which includes assessment information) from a Local Authority care manager. A senior member of staff then completes an initial Hazelwood House Residential Home DS0000054194.V306381.R01.S.doc Version 5.2 Page 9 assessment of the prospective residents needs, with the service users and/or relatives, significant others participation. The relative/significant other usually visits the care home. The manager spoke of residents generally being admitted straight from hospital. There was evidence of assessment information from the social service purchasing authority recorded in care plans inspected. Hazelwood House Residential Home DS0000054194.V306381.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): Standard 7,8,9 and 10 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that resident’s health social and personal care needs are set out in an individual care plan, but there needs to be further evidence of development of some staff guidance in regard to meeting assessed needs of residents. Residents are treated with respect and their right to privacy upheld. Medication is stored and administered to residents safely. EVIDENCE: Four residents’ care plans were inspected. All the care plans inspected recorded evidence of assessment of individual residents needs. There needs to be further development in recorded staff guidance in regard to action to be taken by staff to meet some needs of residents. This includes guidance to meet the needs of residents that might challenge the service. Records indicated that there were two service users who had presented as challenging at times. These challenging behaviour episodes were appropriately Hazelwood House Residential Home DS0000054194.V306381.R01.S.doc Version 5.2 Page 11 recorded but there needs to be clear staff guidance in place to ensure that there is a consistent response and action taken by staff during these episodes. Further development in staff guidance in regard to meeting pressure area needs (such as including the need for frequent changes in positioning), and those with diabetic needs (i.e. appropriate recorded guidance re blood testing by staff, and their response in regard to indications/symptoms of hypoglycaemia and hyperglycaemia). Development of staff recorded guidance to meet assessed needs was discussed with the registered manager/provider. A service user receiving respite care and had been living in the care home for 9 days and support had some recorded assessment information from the Local Authority Care management team, and some from the care home, but there was no recorded care plan of needs and recorded action to meet those needs. ‘Daily ‘ progress notes were recorded. This was discussed with the registered manager and needs to be in place. A care plan inspected recorded evidence that the resident had participated fully in developing the plan of care and in the process of reviewing the documentation. This is positive. Care plans recorded evidence of having been regularly reviewed. The documentation recorded in the care plans was generally informative, and included a personal profile of the resident, though one personal profile for a resident recently admitted to the care home had not been fully completed. Assessment information in care plans included risk assessment in regard to falls, manual handling, and orientation. These could be further developed for example to include bathing/showering risk assessment, and in regard to those who have ‘falls’ mats in place beside their bed at night. A previous requirement in regards to care plan documentation had been judged as met. Records confirmed that resident’s healthcare needs are met. Appointments with the GP, dentist, community nurse, chiropodist, were documented. There is evidence of regular monitoring of residents weight. The manager reported that there was one resident’s who had a small pressure sore, and was receiving regular treatment from a community nurse. The manager reported that pressure relieving equipment when needed, is accessible to residents. The care home has a medication policy/procedure. Medication is stored securely. Medication administration records were fully recorded. Records informed the inspector that staff receive medication training. The registered manager confirmed that senior staff that have received this training administer medication to residents. A resident was prescribed several types of eye drops. There needs to be clear recorded guidance in regard to the administration of eye drops. This was discussed with the registered manager, and he supplied the Commission for Hazelwood House Residential Home DS0000054194.V306381.R01.S.doc Version 5.2 Page 12 Social Care Inspection with a copy of recorded staff guidance in regard to the administration of eye drops, following the unannounced inspection. Some eye drops did not have a record of the date of opening or the name of the resident on the eye drops container. Medication received and returned from/to the pharmacist is recorded. Resident’s privacy was observed to be respected during the inspection. Residents spoke of staff being understanding of their needs, and confirmed that they wear their own clothes. Residents have access to a telephone. Records are kept securely. Hazelwood House Residential Home DS0000054194.V306381.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 12,13,14 and 15 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. Arrangements are in place to enable residents to participate in activities of their choice, but there needs to be development in regard to daily activities. Residents maintain contact with family/significant others, as they wish. Meals are varied and wholesome, and pleasantly presented. EVIDENCE: The care home has an activity programme. The format of this document could be improved to be more accessible to residents. Residents spoke of listening to the radio, and enjoying the garden. Residents were seen to access the garden as and when they wished during the inspection, but there was no indication of residents being offered a planned activity a resident spoke of sometimes being ‘bored’. The manager reported that the staff member who generally instigates activities was not on duty. The registered person needs to ensure that all residents are offered activities during the day, which meet their individual needs, and that there be a system in place to ensure that activities recorded on the activity plan are offered to residents even when this staff member is not on duty. Hazelwood House Residential Home DS0000054194.V306381.R01.S.doc Version 5.2 Page 14 The manager reported that some residents had a manicure during the inspection, and that music sessions from musicians are offered to residents every week. He spoke of an annual barbeque having been planned to take place on the following Sunday. A notice in regard to this event was displayed. The care home has access to a car and a minibus for community access and day trips. Care staff confirmed that a variety of activities are offered to residents, which include drawing, trips out, listening to a piano player which take place twice a week, and that some residents receive a choice of books from a mobile library. The manager reported that cultural festivals were celebrated in the care home, and spoke of the ‘annual Christmas party’ that is held every year. A resident asked the inspector the date and time several times during the inspection. It is recommended that there is a clock accessible to residents and that the date be displayed in the communal sitting room. Residents kindly spoke to the inspector about their visitors. This with information from resident’s daily records indicated that there are frequent visitors to the home. This is reflected in the visitor’s record book. A visitor was very positive about the care and support provided by the care home. Residents spoke of going out into the community with relatives. Residents confirmed that they were supported and enabled to make choices. One resident spoke of having choice in regard to the time that she went to bed. Another resident spoke of buying her clothes via a catalogue. This resident spoke very positively of the care she received in the care home. The menu was available for inspection, but was located in a drawer in the kitchen. The registered manager should develop ways to improve the accessibility of the menu to residents, such as the development of pictorial format and displaying it on a daily basis in the communal area of the care home. No resident who spoke with the inspector was aware what was for lunch on the day of the inspection. The lunch provided on the day of the inspection was as recorded on the menu. Recorded meals were judged to be varied and nutritious. Records of food eaten by residents were generally well recorded. The registered person should ensure that if residents eat a different meal that this is clearly documented. Residents spoke of enjoying the lunch provided during the inspection, and of the meals in general. The registered manager reported that there was a resident with particular cultural needs who received meals that met this dietary need and preference. A choice of hot or cold drinks were offered regularly to residents during the day. Hazelwood House Residential Home DS0000054194.V306381.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 16 and 18 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that complaints are dealt with promptly and effectively, and that residents are protected from abuse, but the there should be some further development of some procedures. EVIDENCE: The care home has a complaints procedure. There were no recorded complaints. Residents spoke of having ‘no concerns or complaints’. A resident said that she would speak to a friend or the registered manager if she had a complaint. Staff who kindly spoke with the inspector were knowledgeable of the complaints procedure. The care home has accessible protection of vulnerable adults procedures/guidance, which include the Local Authority guidance and an ‘in house’ procedure. There was recorded evidence that staff had received abuse awareness training, and staff spoke of this training being included in their induction programme and during NVQ level 2 care courses. Staff files contained booklets signed by staff which included a flow chart of the protection of vulnerable adults procedure. The recorded ‘in house’ procedure (located in the policy file) needs to be amended to ensure that there is clarity that the Local Authority, Commission for Social Care Inspection, (and generally police) are informed prior to any investigation taking place. Staff who kindly spoke to the inspector were very knowledgeable of adult protection reporting and recording procedures. Hazelwood House Residential Home DS0000054194.V306381.R01.S.doc Version 5.2 Page 16 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): Standard 19, 24 and 26 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. The location and layout of the care home is suited for its stated purpose, and is well maintained, and very clean. Residents have comfortable personalised bedrooms. EVIDENCE: The inspection included a tour of the premises, which included resident’s bedrooms. The home, including the enclosed garden is well maintained. The garden is an attractive facility, which residents spoke of enjoying. There is accessible garden furniture located in the garden. The manager spoke of a maintenance programme being in place. The home is very clean and has homely features. There is parking for several cars on the forecourt of the care home. Doors to rooms within the care home should be named and possibly include a pictorial format to acknowledge and meet the orientation needs of residents. Hazelwood House Residential Home DS0000054194.V306381.R01.S.doc Version 5.2 Page 17 In regards to health and safety there should be an appropriate shade on the electrical light fitting in a bathroom. Residents who kindly spoke with the inspector spoke of the care home being ‘cosy’ and ‘homely’. There were flowers, plants and a fish tank located in the communal area of the care home. Residents spoke of being happy with their bedrooms. There was evidence that residents’ bedrooms were personalised. A resident spoke of the personal items that she enjoyed. The laundry facilities are located away from food storage and food preparation areas. The home has suitable clothes washing and drying facilities. Hand washing facilities are accessible. Protective disposable clothing such as gloves is accessible to staff. Staff spoke of the dishwasher located in the kitchen not being in use. The registered person, in regard to infection control, and the number of residents and staff, should ensure that the dishwasher is in working order, and used by staff. Records indicated that staff had received some infection control training. Hazelwood House Residential Home DS0000054194.V306381.R01.S.doc Version 5.2 Page 18 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): Standard 27,28,29 and 30 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that staffing numbers and skill mix meet the needs of the residents, and that residents are protected by the care homes’ recruitment and selection procedures. Staff have received appropriate training to ensure that they have the skills and competency to meet the needs of residents EVIDENCE: The staff rota was available for inspection. There are three care staff and the manager on duty in the morning, and two care staff and management staff until six pm. There are then two care staff on duty until 8pm. From 8pm there is one staff on night duty and a ‘sleep in’ member of staff. Staff and residents spoke of having choice when going to bed. Staff spoke of occasions when residents needs change. The registered person/manager spoke of keeping staffing needs under review. Regular review of staffing needs particularly in the evening time should take place, and be recorded. This review should include all the duties that care staff carry out including catering duties and also the meeting of resident’s personal care needs. The manager reported that seven care staff have completed an NVQ level 2 care course, and that two staff were about to commence NVQ care courses. In Hazelwood House Residential Home DS0000054194.V306381.R01.S.doc Version 5.2 Page 19 regard to the twelve staff employed this meets the standard in that over 50 of staff have achieved this qualification. The home has a recruitment and selection policy/procedure. Three staff personnel files were inspected. These incorporated required information and documentation, including satisfactory enhanced Criminal Records Bureau checks. Records confirmed that staff have received appropriate training to develop their skills and competencies. Records and staff confirmed that staff have received an induction programme. Staff spoke of the varied training that they had received. This included manual handling training, medication training, fire training, food and hygiene training, and NVQ care training. Hazelwood House Residential Home DS0000054194.V306381.R01.S.doc Version 5.2 Page 20 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): Standard 31,33,35 and 38 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. The resident’s benefit from an experienced and competent management approach to the care home. Arrangements are in place to make sure that there are recorded quality monitoring systems in place to ensure that the service provided by the care home is monitored and improved as necessary to meet the aims and objectives of the home. Resident’s financial interests are safeguarded, and the health, safety and welfare of residents and staff are promoted and protected. Hazelwood House Residential Home DS0000054194.V306381.R01.S.doc Version 5.2 Page 21 EVIDENCE: The registered manager/provider has managed the care home for a few years. He is experienced and knowledgeable in regard to meeting the care and support needs of the residents. The registered manager/provider reported that he had completed NVQ level 4 in management and care, and that he updates his skills and knowledge by attending appropriate training regularly. Records, residents, and staff confirmed that there are clear lines of accountability within the care home. A resident and a visitor confirmed that the manager and care staff were very approachable. Care staff confirmed this. The manager’s job description was available for inspection. Arrangements are in place to ensure that the quality monitoring systems in place to monitor the service provided by the care home. Records confirmed that questionnaires are regularly supplied to residents, relatives and significant others including health care professionals. Records informed the inspector that policies and procedures are regularly reviewed, and that a quality audit in regards to staff training had been completed. The registered manager reported that all residents except for one had relatives or significant others that managed resident’s finances. The manager confirmed that he managed one resident’s monies. Documentation in regard to this was available for inspection. Certificates of worthiness of the electrical and gas systems were available for inspection and were up to date Two cracked glass picture frames need replacing. A comprehensive annual health and safety audit had been completed 17/11/05. Radiators are covered. The care home has a fire risk assessment, which recorded evidence of regular review. Fire drills and required fire system checks, and fire equipment checks are carried out. Fire safety procedures are displayed. Several doors within the care home were wedged open. Doors must not be wedged open, and appropriate advice sought from the fire service in regard to safe door mechanisms is needed if doors are needed to be open during the day. Accidents and incidents are recorded appropriately. Hazelwood House Residential Home DS0000054194.V306381.R01.S.doc Version 5.2 Page 22 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 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 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 3 X 3 X X 2 Hazelwood House Residential Home DS0000054194.V306381.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO 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, 18(c) Requirement There needs to be further development in staff guidance in regard to meeting some assessed needs of residents, such as meeting the needs of those who challenge the service, pressure area care needs, and some medical needs. The service user receiving respite care needs to have a comprehensive plan of care. • The registered person needs to ensure that there is always a record of the service users name recorded by the pharmacist on the bottle of all eye drops containers. • The date when the eye drops container/bottle is first open needs to be recorded. • 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 DS0000054194.V306381.R01.S.doc Timescale for action 01/11/06 2 3 OP7 OP9 15 13(2)(4) 01/10/06 01/10/06 4 OP12 12, 16(m) 01/10/06 Hazelwood House Residential Home Version 5.2 Page 24 5 OP18 13(6) 6 OP38 23(4) 7 OP38 13(4) 23 ensure that activities recorded on the activity plan are offered to residents even when the activity staff member is not on duty The recorded ‘in house’ 01/11/06 procedure (located in the policy file) needs to be amended to ensure that there is clarity that the Local Authority, Commission for Social Care Inspection, (and generally police) are informed prior to any investigation taking place. Doors must not be wedged open, 01/10/06 and appropriate advice be sought from the fire service in regard to appropriate door mechanisms being in place to enable doors to remain open during the day. Two cracked glass picture frames 01/10/06 need replacing. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7 Good Practice Recommendations Risk assessments should be further developed for example to include bathing/showering risk assessment, and in regard to those who have ‘falls’ mats in place beside their bed at night. It is recommended that there is a clock and the date displayed in the communal sitting room, which is accessible to residents. • The registered person should ensure that if residents eat a different meal that this is clearly documented. • The registered manager should develop ways to improve the accessibility of the menu to residents, such as the development of pictorial format and displaying it in the communal area of the care home. DS0000054194.V306381.R01.S.doc Version 5.2 Page 25 2 3 OP12 OP15 Hazelwood House Residential Home 4 5 OP19 OP19 6 OP27 The registered person, in regard to infection control and the number of residents and staff, should ensure that the dishwasher is in working order and used by staff. • In regards to health and safety there should be an appropriate shade on the electrical light fitting in a bathroom. • Doors to rooms within the care home should be named and possibly include a pictorial format to acknowledge the orientation needs of residents. The registered person/manager should ensure that there is regular review of staffing needs (which is recorded) particularly in the evening time. This review should include all the duties that care staff carry out including catering duties and also personal care duties. Hazelwood House Residential Home DS0000054194.V306381.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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 Hazelwood House Residential Home DS0000054194.V306381.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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