Inspection on 04/09/06 for Hazelwood Lodge

This inspection was carried out on 4th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 5 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 29/11/07

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 Peter Illes Key Unannounced Inspection 4th September 2006 09:30 Hazelwood Lodge DS0000010581.V304076.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.V304076.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.V304076.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 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) Hazelwood Lodge Limited Mr Seth Obeng Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Hazelwood Lodge DS0000010581.V304076.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th October 2005 Brief Description of the Service: Hazelwood Lodge is a care home registered to provide care for a maximum of ten younger adults 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, laundry room, a toilet and a shower room. On the first floor, there are six single bedrooms (one with ensuite facilities), a bathroom, a separate toilet and the staff office. Washbasins have been provided in all bedrooms without ensuite 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 £970 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.V304076.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took approximately six and a half hours. The registered manager was present throughout and the registered provider was also present for most of the inspection. There were eight long stay service users and one respite service user accommodated at the time of the inspection and one vacancy. The inspection included: meeting and talking to the majority of the service users although this was limited by the complex communication needs of some of them. The inspector spoke to five service users independently as a group, had independent discussions with the deputy manager, a senior care worker and two other care staff and had ongoing discussions with the registered manager and registered provider. Further information was obtained from a range of comment cards from different stakeholders received immediately prior to the inspection, a tour of the premises and documentation kept at the home. What the service does well: The home continues to provide a good standard of care. Service users needs are well assessed and clear care plans, risk assessments and other documentation are produced to assist staff on how to meet these needs. Service users benefit from a management group and staff group that are both stable. The home provides a safe, secure and comfortable place for service users to live in that they like. The home continues to provide a choice of healthy meals that service users enjoy and that cater for a range of cultural preferences. The home also continues to positively encourage service users to take part in a range of social, educational and leisure activities. Hazelwood Lodge DS0000010581.V304076.R01.S.doc Version 5.2 Page 6 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. Hazelwood Lodge DS0000010581.V304076.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.V304076.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs of prospective service users are clearly assessed to ensure that the home can meet their needs. Once admitted service users needs are monitored on a regular basis to assist the home continue to meet their changing needs. EVIDENCE: Two new service users had been admitted to the home since the last inspection, one being a long stay service user and another being a service user that was on a two-week respite stay at the time. These two service user’s files were inspected along with the files of two other service users that had been accommodated for a longer period. All four service user’s files contained a range of assessment information including information that was available prior to the person’s admission to the home. All four files contained assessment information from the person’s referring authority in addition to assessment information obtained by the home as part of the admission process. The three long stay service users also had two monthly reviews carried out by the home that updated information including that of any of their needs that were changing. Each of the service users had an allocated key worker in the home. Three care staff were spoken to who stated that they were key workers for named service users. One of the key workers confirmed that they contributed to the twoHazelwood Lodge DS0000010581.V304076.R01.S.doc Version 5.2 Page 9 monthly reviews of the service users needs that they were key worker for. The files inspected also included three daily log entries for the individual service user, completed at the end of each shift i.e. early, late and the night shift. The inspector was told that these log entries are also used to monitor service users needs and if they are changing. The inspector had received a comment card from a reviewing officer from one of the referring local authorities since the last inspection. This stated that “After my review and inspection of reports, person centred planning activities, care plan, work experience and other professional input, I felt the home met our clients needs and encouraged ongoing goals and objectives planning”. Hazelwood Lodge DS0000010581.V304076.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users assessed needs along with guidance to staff on how to meet these needs are well recorded in up to date care plans. Service users are assisted to make as many decisions for themselves as they can to promote their independence. Service users are also supported to take appropriate risks in their lives to assist them to safely achieve their aspirations. EVIDENCE: The file for the service user that was on a respite stay contained a current care plan that had been agreed with the referring authority for the two week period of the respite. This was informed by a detailed risk assessment that covered identified risks such as: travelling in the community, general support needed, assistance with personal care, medication and finances. The date on this also indicated that it had been reviewed to ensure it was relevant for the respite stay. This service user’s files also contained previous care plans and risk assessments from previous placements for the home’s information. The three long stay service users files also contained current care plans. These files also contained a record of up to date two-monthly reviews. Hazelwood Lodge DS0000010581.V304076.R01.S.doc Version 5.2 Page 11 The registered manager and staff were observed communicating appropriately with service users throughout the inspection. Service users spoken to indicated that their wishes and views were respected at the home. Two service users had been assisted to join work training schemes run by Mencap since the last inspection and both responded positively when asked how they were enjoying this. Where limitations are in place for service users these are recoded in their care plans. One service user that was able to travel independently but had complex needs had limitations on specified activities agreed with them. Evidence was seen that the registered manager had undertaken in-depth counselling sessions with that service user since their admission to the home. This was to ensure that these limitations were understood and subsequently reinforced. Both the registered manager and the service users had signed the records of these sessions. The home had a risk management policy that was seen included in the home’s policies and procedures folder. Evidence was seen on the files inspected of good quality and individual risk assessments. These identified individual risks and gave guidance to staff on how to minimise these. Evidence was also seen that risk assessments are reviewed and updated if necessary at the same time as the individual’s care plans. Hazelwood Lodge DS0000010581.V304076.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users enjoy appropriate activities including within the local community and also enjoy an annual holiday as part of their basic package of care. The home makes good use of its own vehicle to maximise social and leisure opportunities for service users. However, the home needs to further review the driving arrangements for the vehicle to ensure that health and safety is maximised in this area. Contact with relatives and friends is maintained and encouraged in accordance with the service users wishes. Service users rights and responsibilities are respected and promoted within their daily lives. Service users also enjoy balanced and varied meals that meet their needs and preferences. EVIDENCE: Service users undertake a range of daytime occupation. Two of the eight longterm service users now attend a local Mencap job-training scheme and were enthusiastic about this when spoken to. Others attend a day centre, local college or a combination of both. Two service users choose not to attend external structured day activities. Hazelwood Lodge DS0000010581.V304076.R01.S.doc Version 5.2 Page 13 There was also evidence that service users are supported to go out into the local community, with or without staff according to their assessed needs. Notes on one service user’s file indicated that they had been on a variety of trips over the past three months. These included to: central London and the London Eye; the City airport; the West End and trips to a cinema. Another more able service user had visited friends in other parts of the country including Scotland. Other regular activities service users participate in are visiting a local disco and trips out in the home’s mini-bus. An issue was raised with the inspector about the use of the mini-bus. The inspector was informed that at present only one member of staff is able to drive the vehicle. A concern was raised that the one driver could get tired on occasions. The registered provider stated that the home did have an account with a local mini cab company to assist with the transportation needs of the service users as and when required. A related concern raised was that other staff may have to undertake more domestic duties than would otherwise be necessary if more staff were able to drive the vehicle. The registered persons stated that health and safety was not compromised by the current arrangements. However, following further discussion with the registered persons a requirement is made that the home reviews the use of the mini-bus, who can drive it and endeavours to increase the number of available drivers. This to maximise the health and safety of service users and others regarding the use of the vehicle. Compliance with the requirement will also address the perception raised that other work in the home may not be fairly allocated. A good practice recommendation regarding allocation of work among staff is made in the Staffing section of this report. The inspector was informed that a number of service users and staff went to the Notting Hill Carnival during the recent August bank holiday and enjoyed this. The inspector was also informed that one Muslim service user attends a Mosque with their family for particular religious festivals and the staff take that service user to the Mosque to meet their family when that occurs. All but one service user enjoyed a recent one-week holiday to Blackpool that service users spoken to indicated that they enjoyed. All the current long stay service users have contact with relatives. This ranges from weekly contact to contact at occasions such as birthday’s and Christmas. The inspector received three comment cards from relatives since the last inspection. All were positive, one relative that lives abroad and has regular telephone contact with their service user stated, “…(the service user) sounds well and content. Thanks to Hazelwood Lodge, (the service user’s) quality of life has improved since being there”. The registered manager stated that several service users had friends outside of the home but was not aware of any of these including a sexual relationship. He went on to indicate that service users would be appropriately supported by the home if they did develop such relationships. Hazelwood Lodge DS0000010581.V304076.R01.S.doc Version 5.2 Page 14 Staff were seen to interact appropriately with service users throughout the inspection. Service users are offered keys to their bedrooms and evidence was seen of this. Service users were seen to come and go from the home either with or without staff support as appropriate. Records seen showed who was able to travel unaccompanied by staff and who was not. There was also a section seen on service users files that recorded the name that service users liked to be called if that was different from their given name. The home’s menu was inspected and showed a range of balanced and healthy meals. Service users from different ethnic backgrounds are accommodated and the home endeavours to reflect their needs in the meals on offer. Meals on the menu included fried plantain and yam and stew. Food that was seen stored in the home included these ingredients and all the food seen was appropriately stored and labelled. A requirement made at the last inspection that broken tiles on the kitchen windowsill are replaced was seen to have been complied with. Builders were also in the home to undertake a range of improvement work – see the Environment section of this report for more details. One of the jobs being undertaken was the replacement of kitchen cabinets and the repainting of the kitchen. Service users spoken to stated that they enjoyed the meals provided by the home. Hazelwood Lodge DS0000010581.V304076.R01.S.doc Version 5.2 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users receive appropriate personal support in accordance with their needs and preferences. Their emotional and physical healthcare needs are met including through referrals to a range of community based health professionals as required. Service users are also well supported with their medication although an improvement is recommended to further improve protection to service users in this area. EVIDENCE: Service users personal support needs were identified in a specified section of the care plans sampled and also in the risk assessments seen. These recorded needs ranging from significant individual support with personal care to occasional verbal prompts regarding hygiene. Some service users spoke to were able to indicate that the support they received in this area met their needs. Observation of the staff’s interaction with those service users that were less verbal and discussion with staff generally indicated that service users personal care were satisfactorily addressed. Correspondence from a G.P. was seen on one service user’s file who had been admitted to the home since the last inspection. This stated that the service Hazelwood Lodge DS0000010581.V304076.R01.S.doc Version 5.2 Page 16 user was now outside the G.P.’s catchment area and advising that a new G.P. needed to be sought via the local Primary Care Trust. The registered manager stated that the service user had an appointment to register with a G.P. local to the home later on that day. Evidence to support this was seen. The service user that was on respite retained their own G.P. and contact details were seen on their file. All the other service users were registered with a local G.P. Evidence was also seen of appropriate contact by service users with G.P.’s and other health professionals as required. This included contact with their optician, dentist and attendance at the local general hospital outpatient clinics. Evidence was also seen on files inspected that local learning disability health professionals, including the consultant psychiatrist where appropriate, support service users. The home had an appropriate medication policy that the registered manager had reviewed in 2005 and also a record to indicated that it would be reviewed again in 2007. The Primary Care Trust and local authority for the area the home is situated in has recently produced its own medication guidance. This is for services those authorities contract with to further assist in this area. A good practice recommendation is made that the home acquires a copy of the guidance and reviews its own medication policy in the light of this. Medication and medication administration record (MAR) charts for three service users were inspected at random and found to be satisfactory. A local pharmacist supplies medication to the home using a weekly monitored dosage system. The inspector was informed that this worked well and records of medication received into the home and returned to the pharmacist were satisfactory. The inspector was pleased to see that a requirement made at the last inspection to ensure that medication received from the pharmacist was correctly labelled when received by the home had been complied with. A satisfactory daily record of the temperature that medication is stored at was also seen. Hazelwood Lodge DS0000010581.V304076.R01.S.doc Version 5.2 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and relatives are able to express their views and concerns and have these appropriately addressed by the home and other relevant authorities. Service users are also protected by satisfactory adult protection policies and procedures. EVIDENCE: The home has a satisfactory complaints procedure and a clear summary of this was seen displayed in the home’s entrance hall. The CSCI had received an anonymous complaint about the home since the last inspection that resulted in an additional visit to the home. The elements of the complaint were that service users were not being cared for properly, were not being fed properly and that the home was employing care staff illegally. There was no evidence to substantiate the elements of the complaint from that visit and the care to service users including the meals supplied were seen to be satisfactory at that stage. There was also no evidence that staff were being employed illegally with a range of satisfactory documentation being seen at the time to substantiate this. Two requirements were made from this additional visit however, one of them urgent, as two newly appointed bank staff did have a satisfactory criminal records bureau (CRB) check but did not have the required protection of vulnerable adults (POVA) clearances at that time. The inspector was pleased to have received evidence from the home soon after that additional visit that the requirements had been complied with and that the situation had been rectified. This was confirmed by inspecting relevant documentation at this inspection. No other complaints had been recorded at the home since the last inspection. Service users spoken to and feedback forms from them indicated Hazelwood Lodge DS0000010581.V304076.R01.S.doc Version 5.2 Page 18 that they knew how and who to complain to if they did have an issue or concern. The home had a satisfactory adult protection policy that was seen. The inspector was also pleased to see that the home had acquired a copy of the local authority adult protection policy for the area it is situated in as required at the last inspection. One allegation regarding a service user at the home had been reported to the local authority by an external source since the last inspection. Evidence was seen that this had been appropriately investigated by the local authority and had not been substantiated. The registered manager stated that a meeting was being set up with the external source to explore how communication between the home and the external source could be improved. Apart from the anonymous complaint described above no other adult protection issues had been raised regarding the home. Hazelwood Lodge DS0000010581.V304076.R01.S.doc Version 5.2 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27 & 30 Service users live in a home that is comfortable and was undergoing a range of redecoration and refurbishment work at the time to further meet their needs. The bath and shower facilities for service users are adequate although may be further improved by reviewing the way hot water is provided. The home was clean and tidy throughout creating a pleasant environment for those that live and work at the home as well as for those that visit it. EVIDENCE: The home remains comfortable and meets the needs of the service users accommodated. Requirements made at the last inspection regarding routine maintenance had been complied with. These were that: the curtains in one identified service user’s bedroom are repaired and rehung; the ceiling in one identified service user’s bedroom is repaired and re-decorated and that the sofa in the lounge is repaired or replaced. Another restated requirement to replace the floor in the laundry room was also seen to have been complied with. During the inspection decorators were being employed to undertake a range of work. The registered provider showed the inspector a list of the work being undertaken. This included: redecorating seven of the service users bedrooms, renovating the ground floor shower room including laying a new floor, painting the lounge and dining room and replacing units and Hazelwood Lodge DS0000010581.V304076.R01.S.doc Version 5.2 Page 20 repainting the kitchen. The registered provider stated that he felt it was important for the premises to look attractive as well as for the care to be good in the home. At the last inspection a requirement was made that the home must ensure that the hot water in the home is of a satisfactory temperature at all times. This was because the water had been cold despite the hot water boiler being ignited. The hot water was of a satisfactory temperature during this inspection. The registered provider and registered manager acknowledged that the supply of sufficient hot water had caused some concern over a period of time and were keen to see how this could be addressed more effectively. Following further discussion with the registered persons a good practice recommendation is made regarding this. The home should review the hot water system and consider replacing it with a system that can more efficiently supply constant hot water at all times. The home had satisfactory laundry facilities that were seen. As stated above the laundry floor had been replaced so that it is now impermeable. Evidence was seen that staff had completed infection control training from a local college over a fourteen-week period since the last inspection. The home was generally clean and tidy throughout although the building and decorating work that was being carried out at the time caused some inevitable mess and disruption. Hazelwood Lodge DS0000010581.V304076.R01.S.doc Version 5.2 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A competent and effective staff team are deployed in sufficient numbers to effectively address service users needs although further attention in an identified area may further improve staff morale. An appropriate recruitment procedure contributes towards service users protection. Service users are supported by staff who receive appropriate training opportunities. EVIDENCE: The home’s deputy manager has completed his registered manager’s award. Five of the other eight care staff have also completed their national vocational qualification (NVQ) at level 2 or level 3 in care. This meets the national minimum standard that at least 50 of care staff have achieved at least NVQ level 2 in care. Staff spoken to presented as being interested, motivated and committed to the work of the home. However one staff member expressed their view that on occasions work tasks were not necessarily fairly shared out between male and female staff. Following discussions with the registered persons about this perception a good practice recommendation is made. The home should monitor and review how work tasks are allocated amongst staff on a day-to-day basis and within the exigencies of the service, to promote the perception of a fair gender balance within the allocation of these tasks. Hazelwood Lodge DS0000010581.V304076.R01.S.doc Version 5.2 Page 22 The home had a satisfactory staff rota that was seen. The rota showed three staff on duty on the early shift, three staff on the late shift and one waking and one sleeping-in staff at night. This level of staffing was considered satisfactory for the current service users. The staff on duty during the inspection matched those recorded on the rota. A requirement had been made at the last inspection that all staff are given as much notice as is possible of the hours they are expected to work, within the exigencies of the service. The inspector was informed that this requirement had been complied with. The home has a satisfactory staff recruitment policy. No new staff had been recruited since the last inspection although the registered manager stated that the home was in the process of recruiting new staff currently. Requirements made at the additional visit to the home as described in the Complaints section of this report had been complied with. The staff file for the one bank staff member in question who was still employed at the home was inspected. This included all the required documentation to evidence a satisfactory recruitment process. This included: a satisfactory criminal records bureau (CRB) check with a protection of vulnerable adults (POVA) clearance, two references, proof of identity and a satisfactory application form. The registered persons were both clear on the importance of ensuring all satisfactory documentation was in place before a new member of staff commenced their duties. Staff training profiles were sampled and showed a commitment to staff training by the home. The records seen showed that staff had completed a satisfactory induction to the home and a range of relevant core training. It was noted that some staff needed refresher training in some core areas in the imminent future. The registered persons confirmed that they were aware of this and the training was in the process of being booked. Hazelwood Lodge DS0000010581.V304076.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from an effective and stable management group that run the home effectively. They also benefit from a range of systems to monitor the quality of care provided by the home although an identified improvement is needed in this area. Health and safety procedures contribute to protecting service users, staff and visitors to the home although identified improvements are needed to ensure that this protection is maximised. EVIDENCE: The registered manager confirmed that he has a nursing qualification, a management qualification, a health facility planning qualification and substantial management experience. The home has a stable management team and evidence of good quality management systems was seen. Feedback from the service users and staff were positive about the registered manager. Two issues were raised by staff about driving the home’s mini-bus and about allocation of work. These were bought to the registered persons attention at the inspection and are recorded respectively in the Lifestyles and Staffing Hazelwood Lodge DS0000010581.V304076.R01.S.doc Version 5.2 Page 24 sections of this report. Both registered persons reacted in a positive way when these issues were raised and the inspector is confident that they will deal with these in an appropriate and sensitive manner. The home has a range of ways of obtaining feedback from stakeholders about the quality of care in the home. The key worker system is one of these and feedback from reviews is another. The home also undertakes formal stakeholder surveys although the last one of these was undertaken over twelve months ago and a requirement is made regarding this. The home has objectives for 2006, one of them being significant improvements to the physical environment of the home. Evidence was seen and is recorded about this in the Environment section of this report. The deputy manager stated that he had completed a course in fire safety since the last inspection and was now competent to train other staff in this area. Satisfactory records were seen of monthly fire drills and weekly fire call point checks. The registered person stated that he had taken much of the health and safety documentation away from the home temporarily to fill out a questionnaire for the CSCI that had been requested for the end of September 2006. He stated that this documentation was up to date. However, a requirement is made that up to date documentation in the following areas must be kept available for inspection in the home at all times and that copies of these are also sent to the Commission: a gas safety certificate, electrical installation certificate and evidence of portable appliance testing. During the tour of the building it was noted that labels on the fire extinguishers indicated that they were now due for an annual service having last been serviced in July 2005 and a requirement is made regarding this. There was a satisfactory fire evacuation plan displayed around the home. However, a fire door leading from the dining room to the garden was locked with a key that staff carried with them. A requirement is made that the fire officer is consulted about this and that the home’s fire plan and risk assessment are amended if necessary following the fire officer’s advice. There was evidence that the home was reviewing its overall health and safety procedures. As part of this the home is in the process of allocating named staff as safety officers in the following areas: fire safety, transport, first aid, medication, COSHH, food hygiene, maintenance and electrical equipment. The overall judgement for this section of the report is “good” on the basis that the registered persons have identified a range of issues and are actively working to improve them. It is important therefore that the requirements made are fully complied following this inspection to sustain this judgement. Hazelwood Lodge DS0000010581.V304076.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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 2 X Hazelwood Lodge DS0000010581.V304076.R01.S.doc Version 5.2 Page 26 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 YA14 Regulation 13(4) Requirement The registered persons must ensure that the home reviews the use of the mini-bus, who can drive it and endeavours to increase the number of available drivers. This is to maximise the health and safety to service users and others regarding the use of the vehicle. The registered persons must ensure that service users and other stakeholders are formally consulted about the quality of care in the home on an annual basis. The registered persons must ensure that the home has up to date documentation available in the home in the following areas and that copies of these are sent to the Commission: a gas safety certificate, electrical installation certificate and evidence of portable appliance testing. The registered persons must ensure that the home’s fire fighting appliances are serviced annually. The registered persons must ensure that the fire officer is DS0000010581.V304076.R01.S.doc Timescale for action 30/09/06 2. YA39 24(1) 30/09/06 3. YA42 13(4) 30/09/06 4. YA42 23(4) 30/09/06 5. YA42 23(4) 30/09/06 Hazelwood Lodge Version 5.2 Page 27 consulted about an identified fire exit door being locked with a key held by staff and that the home’s fire plan and risk assessment are amended if necessary following the fire officer’s advice. 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 YA20 Good Practice Recommendations The home should acquire a copy of the latest medication guidance issued by the Primary Care Trust and local authority for the area the home is situated in that is designed to further assist services those authorities contract with. The home should then review its own medication policy in the light of this guidance. The home should review the hot water system and consider replacing it with a system that can more efficiently supply constant hot water at all times. The home should monitor and review how work tasks are allocated amongst staff on a day-to-day basis and within the exigencies of the service, to promote the perception of a fair gender balance within the allocation of these tasks. 2 YA27 3 YA32 Hazelwood Lodge DS0000010581.V304076.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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 Lodge DS0000010581.V304076.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. 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