Inspection on 29/11/07 for Hazelwood Lodge

This inspection was carried out on 29th November 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 no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hazelwood Lodge 07/05/09

Hazelwood Lodge 04/09/06

Hazelwood Lodge 06/10/05

Hazelwood Lodge 13/06/05

Hazelwood Lodge 16/12/04

Hazelwood Lodge 14/06/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Hazelwood Lodge 148 Chase Road Southgate London N14 4LG Lead Inspector Duncan Paterson Key Unannounced Inspection 29 & 30 November 2007 10:30 Hazelwood Lodge DS0000010581.V346346.R01.S.doc Version 5.2 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 Lodge DS0000010581.V346346.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 Adults 18-65. 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 Lodge DS0000010581.V346346.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hazelwood Lodge Address 148 Chase Road Southgate London N14 4LG 020 8886 9069 020 8882 6215 sudi@hazelwoodlodge.co.uk www.carehomes.co.uk/hazelwood Hazelwood Lodge Limited 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) Mr Seth Obeng Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Hazelwood Lodge DS0000010581.V346346.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th September 2006 Brief Description of the Service: Hazelwood Lodge is a care home registered to provide care for a maximum of ten younger adults (18-65 years) with learning disabilities. The home is owned by Hazelwood Lodge Limited. The home is situated in a pleasant residential area and within walking distance of the shops, underground station and other transport links of Southgate, North London. The home is a detached house divided into two floors. On the ground floor, there are four single bedrooms, a kitchen, lounge, dining room, a toilet and a shower room. On the first floor, there are six single bedrooms (one with en suite facilities), the newly relocated laundry room, a bathroom and a separate toilet. Washbasins have been provided in all bedrooms without en suite facilities. The front of the building is paved and there is parking for cars. The large back garden is partly paved and accessible to service users. It is attractive and contains a variety of trees and shrubs. The registered provider stated that the fees for the home are from £1100 per week depending on the assessed needs of the service user. The registered provider also stated that information about the home, including CSCI inspection reports, are shared with stakeholders and CSCI inspection reports are available on request from the home. The stated aim of the home is to meet the different and individual needs of service users and to maximise their potential for independent living. Hazelwood Lodge DS0000010581.V346346.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection took place on 29th and 30th November 2007. The second day of the inspection was necessary in order to meet the manager and to check staff records. The inspection involved speaking with the people using the service, the staff on duty and the manager. A standard form, the Annual Quality Assurance Assessment (AQAA), was returned to CSCI by the manager. This was taken into consideration. The inspection also involved the case tracking of three people’s care, the assessment of a range of the home’s records, procedures and forms as well as observation and a tour of the premises. Discussions were also held on the telephone with relatives and care managers. What the service does well: What has improved since the last inspection? The major improvement has been the redecoration and refurbishment of the home. During the summer of 2007 the entire home was decorated with new flooring and carpets laid. Additional improvements have been made such as the installation of a new boiler and refurbishment of the bathrooms and kitchen. Modern, clean and welcoming facilities are now provided. A quality assurance policy and procedure has been drawn up and questionnaires sent out to relatives and others. Many have now been returned. Hazelwood Lodge DS0000010581.V346346.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Hazelwood Lodge DS0000010581.V346346.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hazelwood Lodge DS0000010581.V346346.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 123&5 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Assessment information held about people using the service is detailed and provides staff with relevant information to inform the service. There is a need to update the statement of purpose so that the aims of the service are made clear to all. EVIDENCE: I used the CSCI case tracking method throughout this inspection to assess the quality of the service. This involved selecting three people using the service and looking in detail at their care plans and other records held in the home. It also involved talking with people using the service about the care provided as well as talking with staff and the manager. I also spoke on the telephone, where possible, with relatives and care managers. This allowed me to reach an overall judgement about the quality of the service provided. I was shown the statement of purpose and a leaflet which provided details about the service. The statement of purpose needs to be updated. The document was dated 2002 and referred to the service being an older person’s service. The manager confirmed that the document was the one currently in use. The leaflet was updated in May 2004 and provides a useful short introduction to the service. The statement of purpose needs to be updated so that it accurately reflects what service is provided. This presents an opportunity for the service to use this as a means to relaunch the service and Hazelwood Lodge DS0000010581.V346346.R01.S.doc Version 5.2 Page 9 market it with local authorities and others who may wish to buy the service. The service that is provided is broad. There are people using the service with some independent needs who require support but also some people with the need for a great deal of personal care. There had not been any recent admissions to the service. I spent time discussing with staff first about their understanding of the needs of people using the service and referring to the files the service keeps for each person. It was not possible to speak with everyone using the service. In some instances, where people have difficulties speaking, I observed interactions with staff and others. The people to whom I spoke generally gave positive feedback about the service. They told me that they liked living at the home and that they had freedom to do the things they wanted. One person said that she liked the security offered at the home. I could see that people using the service had a wide range of needs and that staff had a variety of skills and had mostly competed NVQ training. One person does not have English as his first language. Relatives told me that the registered person was able to talk to him in his first language. Comments from some relatives and care managers suggests that more communication with them about what they are doing with each person using the service would be helpful. I saw examples of contracts on the sample of files which I looked at. The contracts had been adapted from a professional care organisation that produces standards policies and procedures as well as forms and guidance. The format is adequate but the owner may wish to produce dedicated contracts for the service. Hazelwood Lodge DS0000010581.V346346.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6 7 8 9 10 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. There are some good quality care plans in place which are regularly reviewed. They provide detailed information about how the staff are working to meet people’s needs. The manager and staff have successfully started adopting a person centred approach and there are opportunities to improve the service further such as involving people using the service in the management of their finances. EVIDENCE: Using the case tracking methodology I looked in detail at three people’s care and I also looked at the care plans for one other person living at the home. I also spoke with the manager, deputy manager and staff on duty and where possible the relevant keyworker from the staff team. I could see that the care plans in use were well organised, up to date and detailed about the care and support provided. Discussions with staff revealed that staff members knew the people using the service well and they were able to confirm that the actions on the care plans were indeed carried out. In fact, in most cases discussions with Hazelwood Lodge DS0000010581.V346346.R01.S.doc Version 5.2 Page 11 staff revealed that more care and support, such as assistance with shopping and outings, actually took place than was recorded on the care plans. I had a discussion with the deputy manager and manager about the extent to which care planning was now conducted using person centred care methods. The managers were well aware of these principles and had been successful in introducing them into the care planning arrangements. I could see that there were regular reviews of the care plans with quite a lot of staff input. There were some excellent examples of two monthly reviews which had been recorded by staff. I saw that there were some good examples of assisting people using the service to make decisions. A number of people using the service make decisions about every aspect of their lives from going to work, to activities and who they socialise with. Others are encouraged by staff to make decisions about everyday matters such as food and clothes and activities. I observed staff working positively and sensitively with the people using the service. Having said that, there is a paternalistic side to the care arrangements. One example is the arrangements for looking after people’s money. It was difficult to fully assess these arrangements as the registered person (the service owner) was on holiday during the inspection. The manager told me that the owner brought money weekly to the home to cover the petty cash allowance and the personal allowance for people using the service. Staff did not get involved in managing the resident’s finances other than the weekly personal allowance. The owner was doing all of this. I saw records of how the personal allowance was managed and I saw that very clear records were kept and that people’s money was being carefully looked after. This was confirmed through discussions with people. There is no suggestion of impropriety but there is possibly something of a missed opportunity here in that people using the service are not able to be fully involved in the management of their finances. It would not be possible for everyone to be involved and they would need people to safeguard their money where they do not have capacity. But where people have capacity it will be worth considering extending, where possible, choice and decision making to those individuals, obviously with staff and/or external advocate assistance. I was advised that one person manages her own allowance account with support from staff as required. This provides an opportunity for staff to build on in their work. I saw records of regular meetings of the people using the service and this is a good opportunity to enable people to make important decisions about their lives. There were risk assessments on individual files which set out the arrangements for identifying and managing risk. The records are held securely in the home’s office. Hazelwood Lodge DS0000010581.V346346.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11 12 13 14 15 16 & 17 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The manager and staff have been successful in arranging a daily programme for each person using the service. The variety of needs of the people have been addressed with people supported to either work, attend day centres or college and to take up leisure activities. Meals provided are traditional in the main with some scope for catering for individual tastes and needs. EVIDENCE: I could see that each person using the service has a programme of activities and is involved, to a greater or lesser extent, in the community I was able to talk to staff and the people using the service about this as well as make observations. Care plans also contained details of activities. Three of the people using the service work, others go to day centres or attend college. I was told that staff were arranging for one person to go to a day centre and were discussing fees with the relevant local authority. Staff demonstrated a good understanding of the people using the service, their needs and Hazelwood Lodge DS0000010581.V346346.R01.S.doc Version 5.2 Page 13 preferences and it was clear that they were being active in assisting people to find day centre or college places as well as work. In addition to the above I could see that people using the service were also involved in going to social activities such as a weekly disco and going out for meals. I also noted that staff were taking people out individually, for example, to go shopping or to the cinema. I noted that one person was assisted to go to a church on a regular basis. I was able to speak with three relatives on the telephone. One was very happy and told me that the staff looked after her relative, “very well”. Another said that there had been an issue to do with assistance to take her relative to a mosque but that had been sorted out. She referred to the staff as, “good people”. There is a minibus with the deputy manager out driving it on both days of the inspection. He was taking people to their daily activities such as day centres. The people using the service who work travel by their own means. I was told that many of the people using the service go out in the minibus even if they are not going to a day centre. After dropping some of the people off the pattern is that a shopping trip or a social trip then takes place. I was able to observe two meals during the inspection as well as have discussions with staff. The main meal is provided in the evening. This was cooked by a member of staff and all the people using the service had the meal together. The meal was an attractive looking dish of chicken casserole and rice. The people using the service did not help staff to make the meal but they told me that they helped to clear away and wash up afterwards. The arrangements were efficiently arranged and there was sufficient and nutritious food. I looked at the week’s menu which was displayed in the kitchen. I noted that the meals served tended to be a traditional form of food. One of the issues is that they are providing food for nine people so that makes innovation quite difficult. I discussed this with the manager who advised that different meals could be and were provided for people depending on their choice or culture. For example, yams were often provided. And a different lunch was provided to one person with staff having been advised as to the person’s wishes by a relative. Hazelwood Lodge DS0000010581.V346346.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18 19 & 20 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. There are good quality records relating to personal care provision as well as health care needs. Feedback from relatives and care managers suggests that more detailed communication is needed from the service about how they are addressing people’s needs. Good, competent medication arrangements are in place with a good example of insulin management. EVIDENCE: In order to assess these standards I read care plans, held discussions with staff and the people using the service. I also made observations. I could see that the arrangements for personal care were good. The care plans set out the tasks that needed to be done and areas to concentrate on. Staff, in my discussions with them, demonstrated that they were knowledgeable about people’s needs and keyworkers had a good understanding. Each person using the service has been allocated a keyworker. This was helped by the fact that many of the people using the service had lived there for many years and similarly, staff had worked at the home for a long time. Three to four years was typical for staff. There was some feedback from relatives which questioned how staff worked with those people using the service who needed extensive personal care and Hazelwood Lodge DS0000010581.V346346.R01.S.doc Version 5.2 Page 15 were not able to verbalise their needs. The manager and staff will need to bear this in mind and address through reviews and or communication with relatives. A good example of the benefits from such consistency was that staff had been able to take responsibility for the administration of insulin for one person. I was shown the records for the administration, which were clear and well ordered, and for the checking of blood sugar levels. Staff had received relevant training and the regularity of staff meant that fewer people were involved in the arrangements thereby reducing the chances of mistakes occurring. Such an arrangement is not always suitable for care homes but it was working well at this service. I saw on the case files I looked at evidence that regular appointments had been made with health care professionals including psychiatrists and preventative health care professionals such as GPs and dentists. One of the people using the service to whom I talked said that she went herself to the GP and dentist but informed staff when that had happened. Staff assisted other people using the service to go to health care appointments. Having said that I received feedback from a local authority care manager that making an appointment to check a particular health issue for one of the people using the service was taking a long time. This will need to be addressed by the staff. I reviewed the medication arrangements by looking at the medication storage and records of administration. There is a new medication storage cupboard which provides ample room for neat and secure storage. The cupboard was very well arranged. The Boots medication system is used which provides a convenient blister pack style allowing medication to be available in colour coded packs for each person at the designated time each day. There were relatively small amounts of medicines in use with many of the people using the service not in receipt of any medication at all. The good standard of insulin arrangements has been mentioned above. Overall, a very good standard had been achieved in this area. Hazelwood Lodge DS0000010581.V346346.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The complaints details are clear and on display within the service. The Safeguarding Adults arrangements will be improved by the provision of training to staff and by the drawing up of a single policy that provides staff with clear instructions of the actions to take. EVIDENCE: I was shown the complaints record book. No complaints had been received since the last inspection of 4 September 2006. The complaints policy was on display in the entrance way. Suitable arrangements for making complaints have been made. There had been a recent Safeguarding adult concern raised about the service which involved a local authority Safeguarding Adults strategy meeting. I was told by the manager that the matter had been concluded satisfactorily although CSCI has not received minutes of the meeting to confirm this. I reviewed the home’s Safeguarding Policy and discussed staff training with the manager. I was shown two Safeguarding policies. Taken together there was sufficient information for staff and others to inform them of the actions to take following an incident or allegation of abuse. However, there is a need for a review of the policies with the aim of having one policy that is clear and gives clear instructions to staff. A recommendation is given about that. The manager told me that, with the exception of the deputy manager, staff had not received Safeguarding Adults training. Given that there has been a recent Safeguarding Adults issue at the service and that there is a need to Hazelwood Lodge DS0000010581.V346346.R01.S.doc Version 5.2 Page 17 keep up to date with such topics a requirement is given that staff be provided with Safeguarding Adults training. The local authority should be approached to see if they are able to provide this training. Hazelwood Lodge DS0000010581.V346346.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 25 26 27 28 29 & 30 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Extensive redecoration and refurbishment has taken place and the home now provides a comfortable, attractive and homely place for people to live. Refurbished bathrooms, redecorated bedrooms and the provision of a new boiler and laundry area has greatly enhanced the facilities available for people using the service. EVIDENCE: The physical standards have been transformed since the last inspection. Over the summer of 2007, whilst the people using the service were away on holiday, the home was redecorated. New flooring and carpeting has been laid, windows replaced, bathrooms renewed and a new kitchen and boiler provided. There had been further changes with the move of the office downstairs which meant that two of the bedrooms upstairs had been extended. Both people using the service and staff were proud of the new environment and felt that it provided a modern, clean and comfortable home for everyone. The assistant manager gave me a tour of the home and I was able to see a selection of bedrooms as well as the communal parts of the home. The Hazelwood Lodge DS0000010581.V346346.R01.S.doc Version 5.2 Page 19 bedrooms I saw were all pleasantly decorated with nice features such as large windows. Each person had brought some personal possession such as photographs or mementos so that the bedrooms were nicely personalised. There is a shower room on the ground floor as well as a bathroom on the first floor. Both of these had been modernised during the recent physical improvements at the home. Both were suitable with the bathroom particularly homely and welcoming. There are two communal rooms: a living room and a dining room. These rooms provide a choice for the people using the service although space may be a little limited should all ten residents wish to sit in the lounge together. What I observed during the inspection was that the people using the service tended to sit in the lounge in the main but that some people were either out or they spent time in their own bedroom. None of the people using the service have physical disabilities and there are few adaptations in the home. There is a level access shower and a ramp for access to the front door. The laundry is now located on the first floor. There is a washing machine and dryer. Hazelwood Lodge DS0000010581.V346346.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31 32 33 34 35 36 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The staff team has many years experience of working together and is able to provide a consistent service. Currently, this consistency is affected by the fact that some staff are working long hours to accommodate a lack of numbers in the overall staff team. There is a need to recruit more staff. Staff have received relevant training and supervision but the retention of these records needs to be reviewed so that they are accessible to the manager on a day-to-day basis to allow for the smooth and efficient running of the service. EVIDENCE: The management team and staff were all co-operative and friendly. I could see that there were good relations in the staff team as well as with the people using the service. As stated earlier in the report, there are great benefits from the fact that many of the staff team have worked at the home for a number of years and that they know each other and the people using the service well. Staff were also knowledgeable about their role and told me that they had received relevant training and completed NVQ qualifications. The manager and deputy had completed the Registered Managers Award (RMA). I could also see that there was a great deal of goodwill and commitment from the staff to make sure that the service ran well and that people using the service were well cared for. Hazelwood Lodge DS0000010581.V346346.R01.S.doc Version 5.2 Page 21 I did not look extensively at staff recruitment, as there had been no new staff appointed since the last inspection. This meant that all the available staff recruitment documentation had been looked at during the last inspection visit and therefore the standard continues to be met. I did identify two matters which will need to be addressed. One, the staffing numbers. I looked at the current staff rota. I could see that there were adequate numbers of staff on duty for each shift. Typically, in addition to the manager, there were three staff on duty on each day shift with two staff providing a waking night service. However, this was achieved by staff working additional hours. For example, the deputy manager was working a 75 hour week during the week of the inspection. Two staff were working the early shift after having completed a waking night shift. This places considerable demands on staff and may potentially place people using the service at risk because staff may be tired when carrying out their duties. I was told that some staff had left since the last inspection and that one member of staff was on maternity leave. The manager said that they are working towards recruiting new staff. Recruitment needs to take place so that the good standards of care from a consistent staff team continues. A requirement is given about this. There were difficulties in locating staff training records and staff supervision records. However, following the inspection the registered person provided me with the records of staff training and supervision. I shall discuss the training records first. The staff I spoke with told me that they had received relevant training and that they had completed NVQ qualifications. I asked to see training records and I was shown a sample. I was also shown a record (completed in August 2006) detailing each member of staff and what training they had had. Some of the training certificates, to verify staff training, were available on the staff files. However, some were not and the manager told me that that may have been because the owner had a role in checking training and may have removed some of the certificates temporarily. The manager also said that the training record had not been updated since 2006. I was therefore unable to confirm that staff had received the full range of training needed for this work. Following the inspection I was given records of staff training that had been completed on 19 May 2007. However, staff and the manager had told me that the training had taken place so I considered the matter to be more of how the records were stored and maintained rather than a lack of training. This was confirmed through the receipt of more up to date training records. One further matter that would improve the storage of training records was that the records were held in a suspension files together with other staff related papers such as recruitment Hazelwood Lodge DS0000010581.V346346.R01.S.doc Version 5.2 Page 22 records. There was one suspension file per staff member. Separating out the information and also keeping a computer log would make training records easier to retrieve. There was a similar situation in regards to staff supervision records. I was shown records relating to recent supervision that had been provided to the deputy manager and one other staff member. Unfortunately, the other staff supervision records were not available. The manager thought that the owner may have removed them again temporarily. Again, following the inspection I was provided with staff supervision records that covered all the staff. Staff had told me that they had received supervision and again I concluded that the issue was more about the retention and storage of information. This was confirmed by the receipt of the supervision records after the inspection. However, I noted from looking through the supervision records that there is a need to increase the frequency of supervision sessions. The recorded supervision sessions for some staff was infrequent. This is part of a wider issue relating to the administrative organisation of the service. More details are provided in the next section. A requirement is given about staff supervision and having the records available for the manager. The requirement covers the frequency of supervision sessions. There could be potential problems and a possible poorer service provided for people using the service if the manager is not able to quickly access records such as staff training and supervision. Hazelwood Lodge DS0000010581.V346346.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37 38 39 40 41 42 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The management arrangements are clearly organised resulting in the provision of a flexible, informed and ordered service. However, these arrangements are let down by an administrative system which is erratic in parts. Ordering the new office and providing adequate storage for records will assist in greater efficiency as will the provision of modern facilities such as email and internet access. EVIDENCE: The manager is competent and qualified and has been working at the service for many years. He is supported by a bright deputy manager and by a staff team which has been together for a number of years. A consistent, well organised, flexible and friendly service is provided with staff motivated to care for the people using the service. Hazelwood Lodge DS0000010581.V346346.R01.S.doc Version 5.2 Page 24 There are many positive aspects to the service and there is a desire to develop the service and respond to the needs of people using the service as well as new initiatives and the work of others in the field. One example of this is the quality assurance work which has been completed since the last inspection. I was shown a new policy which was detailed and set out a clear pathway to obtaining the views of people using the service and others. I was also shown questionnaires which had been completed by people using the service and their relatives. The manager said that the next step was to compile a report about the findings. From my review of the questionnaires I could see that the majority of responses were positive. There is some very good administration but unfortunately there are some areas that have let the service down. I gave details of the lack or administrative organisation in terms of training and supervision records earlier in the report. In addition to this there were some others difficulties with the retention of records. Some of the records and certificates of the servicing of the home’s equipment and installations were not available to show me. The records were provided to me by the registered person after the inspection. Further, the manager said that the recent move of office from the first floor to a smaller ground floor location had caused some disruption to the filing. Indeed, I observed that the office was a little cramped with a shortage of shelf space for files. The office needs to be ordered so that the service can operate effectively. I also identified that the service did not have an e-mail or internet service and that the computer was broken. It is not a requirement that there should be email and internet accessibility or even that there should be a computer. However, not having such facilities means that there are lost opportunities. Internet access is very useful for obtaining very quickly and easily information relevant to the work and an e-mail account would make dealing with the dayto-day business much easier. A recommendation is given about this. Following the inspection I was advised by the registered provider that arrangements are in hand to set up an efficient administrative system. Also, that the organisation has a registered office in Harrow which provides Internet and e-mail facilities. Hazelwood Lodge DS0000010581.V346346.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 2 3 3 3 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 3 3 2 3 Hazelwood Lodge DS0000010581.V346346.R01.S.doc Version 5.2 Page 26 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA1 Regulation 4 Requirement The registered person must ensure that the statement of purpose is amended and updated. The registered person must ensure that staff are provided with Safeguarding Adults training. The registered person must ensure that records of staff supervision are accessible to the manager, up to date and available for inspection. The registered person must ensure that more staff are recruited so that shifts are more spread out amongst the staff team. Timescale for action 01/03/08 2 YA23 13(6) 01/04/08 3 YA36 18(2) 01/01/08 4 YA33 18(1)(a) 01/03/08 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 YA35 Good Practice Recommendations The registered person should consider the re-organisation DS0000010581.V346346.R01.S.doc Version 5.2 Page 27 Hazelwood Lodge 2 YA43 of the method of keeping the staff records so that staff training details and other information is easier to retrieve. The registered person should consider enhancing the smooth running of the service by obtaining e-mail and internet facilities and by re-organising the file storage arrangements in the office. Hazelwood Lodge DS0000010581.V346346.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow 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 Lodge DS0000010581.V346346.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. 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