Inspection on 14/04/05 for Hazlewell

This inspection was carried out on 14th April 2005.

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

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

Other inspections for this house

Hazlewell 03/03/10

Hazlewell 02/06/09

Hazlewell 18/12/08

Hazlewell 23/06/08

Hazlewell 16/01/08

Hazlewell 16/07/07

Hazlewell 21/04/06

Hazlewell 26/08/05

Hazlewell 01/09/04

Hazlewell 22/04/04

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 Hazlewell 29-31 Hazlewell Road Putney London SW15 6LT Lead Inspector Jon Fry Unannounced 14 April 2005 10:00am th 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 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. Hazlewell G54-G54 S19097 Hazlewell V221707 140405 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Hazlewell Address 29-31 Hazlewell Road, Putney, London, SW15 6LT Telephone number Fax number Email 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 8788 8753 020 8780 5736 Mr D Patel Mrs Rosemary Carmen Molloy Care Home with Nursing (CRH) 29 Category(ies) of OP Old age (29); DE (E) Dementia - Over 65 (1) registration, with number of places Hazlewell G54-G54 S19097 Hazlewell V221707 140405 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: The home may provide accommodation and care for one named service user with dementia. The category DE (E) must be removed once this named service user is no longer accommodated. Date of last inspection 23/08/04 Brief Description of the Service: Hazlewell is a twenty nine bedded care home for older people that provides nursing care. The property consists of two semi-detached Victorian houses that have been combined to make one home. The home is on three storeys and has been extended to the rear with a large conservatory. There is a sizeable rear garden with a patio area available. The home has twenty three single bedrooms and three double bedrooms. Hazlewell is situated in a quiet residential street reasonably close to available shops and transport links in Putney. Hazlewell G54-G54 S19097 Hazlewell V221707 140405 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day in April 2005. A tour of the premises took place and care documentation was inspected. Seven residents and three members of staff were spoken with individually. The previous inspection of the service took place on the 1st September 2004. Further monitoring visits were undertaken in December 2004 and January 2005 due to the continued shortfalls in meeting National Minimum Standards. Enforcement notices were issued in December 2004 with regard to records of food provided, weekly checks of hot water temperatures and monthly visits by the registered provider. These were fully complied with within the specified timescales. What the service does well: What has improved since the last inspection? The registered manager and her deputy have clearly been trying to improve the administration and recording systems in place at the home. Examples seen included individual staff profiles and a new quality assurance system. Records of activities, of meals provided and Health & Safety checks were also seen to be better maintained than at previous inspections. Internal areas of the home have been re-decorated since the inspection of September 2004. This has improved some areas with a number of individual bedrooms presenting well. Hazlewell G54-G54 S19097 Hazlewell V221707 140405 Stage 4.doc Version 1.20 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Hazlewell G54-G54 S19097 Hazlewell V221707 140405 Stage 4.doc Version 1.20 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 Standards Statutory Requirements Identified During the Inspection Hazlewell G54-G54 S19097 Hazlewell V221707 140405 Stage 4.doc Version 1.20 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 standard(s) 1 and 3. Satisfactory documentation is available to both prospective and existing residents. An assessment process is in place at the home. Care must be taken to ensure that the service does not admit residents outside of its current registration categories. EVIDENCE: The Service Users Guide has been updated to include a standard form of contract as issued to all newly admitted residents. The certificate of Registration is now displayed in the front hallway of the home. The assessment documentation in place for one newly admitted resident made reference to the individual having a history of dementia. The service is not currently registered to admit service users with dementia. Hazlewell G54-G54 S19097 Hazlewell V221707 140405 Stage 4.doc Version 1.20 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 9 and 11. Care plan documentation in place for individual residents requires further review and development. Systems for the administration of medication have improved since the previous inspection visit. Minor shortfalls were noted. Information concerning individual wishes following death are not consistently obtained and recorded. EVIDENCE: Care plans in place for three residents were examined. The documentation had been fully completed and a monthly review process was evidenced. Risk assessments were seen to require further review. Full and detailed documentation must be completed with regard to the use of cot side equipment. These were not in place at the time of inspection. The monthly review process must be amended to include both risk assessments and other applicable documentation such as pressure assessments. It is essential that Hazlewell G54-G54 S19097 Hazlewell V221707 140405 Stage 4.doc Version 1.20 Page 10 an ongoing evaluation and review process be evidenced within the care plans maintained. Further development work must be undertaken with regard to ensuring that the care documentation reflects the care of the whole person and addresses social & emotional needs. Daily records maintained must be factual, accurate and provide current information on the care and condition of the individual concerned. A number of entries as observed during the inspection visit stated ‘all care given’ or ‘care continued’. The qualified staff must familiarise themselves fully with the Nursing & Midwifery Council guidelines regarding record keeping. Records examined for the administration of medication were generally well maintained at the time of this inspection. Two minor shortfalls were noted with regard to the refrigerator storage of one medication and the recording of the administration of dietary supplements. Controlled drugs were suitably and securely stored with full records maintained. Pro-forma in place for the recording of individual arrangements following death were not consistently completed. The home must ensure that information is obtained and recorded – where a resident declines to discuss these details, this should be documented as such. Hazlewell G54-G54 S19097 Hazlewell V221707 140405 Stage 4.doc Version 1.20 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 and 15. In–house activities are regularly provided on an informal basis. There is scope for this provision to be developed and improved upon. The meals provided are to a good standard and satisfy the individual taste / choice of residents. EVIDENCE: Daily records of activities provided were seen at the time of inspection. The registered manager reported that there was no structured programme in place but activities generally took place in the afternoon for approximately one hour. There are no dedicated activities staff in post and sessions are facilitated by the care staff on duty. Three members of staff currently working at the home have received training regarding activity provision. Activities provided were seen to include ball catching, music & movement, board games and sing-a-long. Carers were seen to be throwing a ball with service users on the day of inspection. One resident was seen to be supported in playing cards in the main lounge. Other activities recorded referenced residents watching TV, sitting on chair in bedroom and sitting in the main lounge. Trips out into the community for Hazlewell G54-G54 S19097 Hazlewell V221707 140405 Stage 4.doc Version 1.20 Page 12 social / recreational purposes as provided by the home were not evidenced within the maintained record. Further development work must be undertaken to enhance the social and recreational opportunities available to residents. It is essential that a dedicated trained member of staff be provided at the home to lead on activity provision. This may additionally allow for more trips outside the home either individually or in small groups. Care plan documentation must be developed to ensure individual needs are being met in this area. Comments from residents included ‘tedious’, ‘I would like more exercise’ and ‘I would like to go on some trips’. Other residents stated that they were satisfied with the current activity provision. Feedback obtained regarding food was generally very positive. Comments received included ‘the food is good’, ‘the food is pretty nice’ and ‘its quite varied’. Records of food provided were seen to be satisfactorily maintained on the day of inspection. Hazlewell G54-G54 S19097 Hazlewell V221707 140405 Stage 4.doc Version 1.20 Page 13 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 standard(s) 16 The home has a satisfactory complaints system in place. Individual concerns / complaints are fully recorded with outcomes stated. EVIDENCE: The record in place evidenced that individual concerns / complaints are fully logged by the home. Outcomes and timescales were stated within this document. Individual concerns were observed to have been addressed with regard to issues such as missing clothing and quality of meals served. Hazlewell G54-G54 S19097 Hazlewell V221707 140405 Stage 4.doc Version 1.20 Page 14 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 standard(s) 19, 21, 22, 24, 25 and 26. There has been no significant change to the décor or furnishings since previous inspection visits. This does not create a pleasing and pleasant environment for service users and reflects poorly on the registered provider. The current provision of suitably adapted bathrooms is inadequate to meet the needs of residents. A number of individual bedrooms provide homely and comfortable accommodation for residents. This standard is not consistently maintained throughout the home and a number of shortfalls were identified. EVIDENCE: The home has been re-decorated in many areas since the previous inspection. This has however not significantly altered the overall impression that the environment requires further maintenance and redecoration. There is tremendous potential for this service to provide comfortable and homely Hazlewell G54-G54 S19097 Hazlewell V221707 140405 Stage 4.doc Version 1.20 Page 15 accommodation for residents that is of a very high quality. Many areas still present as requiring full renovation – these include the main lounge, ground and first floor hallways and a number of individual bedrooms. Carpets in a number of areas require replacement. This must be an immediate priority within the main lounge, first floor hallway and within rooms 18 & 19. Further consideration must be given to the standard of furniture provided within individual bedrooms. Individual pieces were seen to be worn and present poorly. Individual residents spoken to were generally satisfied with their individual bedroom accommodation. Comments included ‘I’m very satisfied’, my room is alright’ and ‘its ok’. A number of bedrooms present very well and are personalised to the individual. As stated previously, this standard is not consistently maintained throughout. The ceilings in two bedrooms were badly stained – the registered manager stated that this had occurred very recently due to water leaking from a room above. The bath facilities on the second floor are not currently used. This is due to the excessive noise generated from the adapted bath when in use and that the other bath provided has no adaptations fitted. The registered manager reported that the first floor adapted bath and ground floor shower were the actual facilities in use at the time of inspection. It is noted that this was the situation at the time of the last inspection. A number of residents were seen to be utilising the conservatory area on the day of inspection. The registered manager reported that this area became too hot on warmer days due to the lack of shading in this area. An Immediate Requirement was made subsequent to the inspection taking place to ensure that suitable blinds are fitted. A pleasant garden area with raised patio is provided for residents use. The garage located at the back of the garden was open and contained potentially hazardous substances / equipment. The area behind this garage additionally requires clearance. The stair lift facility is still in place at the home and the registered manager reported that this was due to be serviced in the near future. This must be completed immediately or the equipment removed. The sluice area was observed to be in a poor state of cleanliness and presents as requiring full refurbishment. The Requirement from the previous report has been re-stated. One shared bedroom was seen to be used for the storage of equipment / supplies. Suitable storage areas must be identified for these. Hazlewell G54-G54 S19097 Hazlewell V221707 140405 Stage 4.doc Version 1.20 Page 16 One member of staff reported that the manual hoists were hard to use and felt that an electric hoist should be provided at the home. This provision is recommended to aid staff with manual handling tasks. Hazlewell G54-G54 S19097 Hazlewell V221707 140405 Stage 4.doc Version 1.20 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 and 30. Staffing levels are adequate to meet the care needs of residents currently accommodated. Further consideration must be given to ensuring that individual social & recreational needs are being fully addressed. The standard of vetting and recruitment procedures for staff has improved. One issue highlighted at the previous inspection however remains unmet. The training provision for care staff has improved. Further development work is required to ensure that all new staff receive a full induction to Sector Skills specification. EVIDENCE: Staffing levels in place are as follows: Am – 2 qualified / 4 carers registered manager. Pm – 1 qualified / 3 carers registered manager. Night – 1 qualified / 2 carers. Three domestic / laundry staff are additionally provided for morning shifts. Comments from residents regarding staff included ‘the staff are nice & friendly’, ‘the staff are very good’ and ‘very helpful’. Two residents stated that ‘most staff’ were ‘ok’ or ‘alright’. Hazlewell G54-G54 S19097 Hazlewell V221707 140405 Stage 4.doc Version 1.20 Page 18 As stated within the section regarding daily life and social activities, further development work must be undertaken to enhance the social and recreational opportunities available to residents. This would include a dedicated trained member of staff to be provided at the home to lead on activity provision. The staff files examined had been subject to reorganisation and key required documentation had been obtained. The inspector was informed that Criminal Record Bureau (CRB) checks had not yet been obtained for one domestic member of staff and the maintenance person who visits the home regularly. Records pertaining to PIN numbers for qualified staff were in evidence and a procedure was in place for checking these. Individual training records were being implemented at the time of the inspection visit. Recent training provided included First Aid, Fire Safety and manual handling. Planned training events included Food Hygiene and infection control. The induction training materials in place require review to ensure they reflect the national ‘skills for care’ standards. Individual records must be maintained to evidence that new care staff have received this training within six weeks of employment. Records of regular staff meetings were not available at the time of inspection. The last record as held on file was dated February 2004. The registered manager stated that meetings were held every three months but had not been typed as yet. It is recommended that staff meetings should be held every two months as a minimum. Hazlewell G54-G54 S19097 Hazlewell V221707 140405 Stage 4.doc Version 1.20 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 36 & 38 The registered manager requires further administrative support in order to ensure the home is fully meeting National Minimum Standards. This will enable a more pro-active approach to ensuring that the home provides the best possible service to the residents accommodated. A quality assurance system has been developed but requires full implementation. This will further serve to ensure that resident’s views are listened to and acted upon. The system for staff supervision requires review. Appropriate training must be accessed to ensure good practice in this area. Fire Safety equipment / precautions require immediate attention. This potentially places residents safety at risk. EVIDENCE: Hazlewell G54-G54 S19097 Hazlewell V221707 140405 Stage 4.doc Version 1.20 Page 20 The inspector noted that progress has been made with regard to the maintenance of staff records (recruitment / training / appraisal) and that a quality assurance system has been developed for the home. As stated within the previous inspection report, the administrative systems in place require full review and re-organisation. It is essential that further administrative support be provided at the home even for a temporary period in order to achieve this. Completed resident questionnaires were in evidence. A framework for the audit of medication records and care documentation was additionally noted to be in place but not yet fully implemented. Further work must take place to ensure that the information obtained from residents is utilised to inform a development plan for the service. Regulation 26 reports from the registered provider are now being supplied to the CSCI. Individual staff supervision records were available on the day of inspection. The format was seen to require review to ensure that these 1-1 sessions are used for management purposes and not as a tool for ‘clinical’ supervision. It is essential that the registered manager and her deputy attend training to ensure their own good practice in this area. Three members of staff spoken to all reported that the registered manager was supportive to staff. Health and Safety records were well maintained with regard to Fire Alarm testing, weekly monitoring of hot water temperatures and monthly First Aid box checks. A Fire Officer was seen to have visited the home in February 2005 and had requested the home address two issues regarding smoke detectors / disused kitchen equipment. No action had been taken at the time of this inspection. Immediate Requirements were made subsequent to the inspection taking place and are included within this report. Two instances were noted where pressurised air fresheners were not stored securely. All items assessed as potentially hazardous must be kept locked away at all times. The registered manager must ensure that all incidents adversely affecting the welfare of residents are notified to the CSCI. The accident book examined made record of a number of falls that had not been notified as required. One resident was observed to be returning from a Day Centre on the day of inspection. The staff escort was heard to request that footplates be provided in future on the wheelchair in use or the resident would not be able to travel. Hazlewell G54-G54 S19097 Hazlewell V221707 140405 Stage 4.doc Version 1.20 Page 21 Hazlewell G54-G54 S19097 Hazlewell V221707 140405 Stage 4.doc Version 1.20 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 2 10 x 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 2 x 2 2 x 2 2 2 STAFFING Standard No Score 27 2 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 2 x 2 x x 2 x 2 Hazlewell G54-G54 S19097 Hazlewell V221707 140405 Stage 4.doc Version 1.20 Page 23 Yes 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 1 Regulation 14 (1) Requirement The Registered Persons must ensure that residents are only admitted to the home within the current categories of registration. The Registered Persons must ensure that: Individual care plans fully address health, personal and social care needs of residents. All aspects of the care plan are reviewed on a monthly basis or more frequently if required. Daily care notes must be completed in line with NMC guidelines. (Previous timescale of 30/11/04 not fully met) 3. 7 13 (4) 12 (1) 4. 9 13 (2) The Registered Persons must ensure that full and detailed risk assessments are put in place with reference to cot side equipment in use. The Registered Persons must ensure that medication is appropriately stored at all times. 1st June 2005 Timescale for action 1st May 2005 2. 7 12 (1) 15 1st June 2005 1st May 2005 Page 24 Hazlewell G54-G54 S19097 Hazlewell V221707 140405 Stage 4.doc Version 1.20 5. 9 13 (2) The Registered Persons must ensure that medication records are fully and accurately completed at all times. This is with particular reference to prescribed dietary supplements. The Registered Persons must ensure that there is a full programme of activities in place at the home. A dedicated trained member of staff must be provided in order to effectively deliver this programme. The programme provided must enable residents to engage in local, social and community activities. (Previous timescale of 30/11/04 not fully met) 1st May 2005 6. 12 16 (2) (m) (n) 1st July 2005 7. 19 23 (2) (b) (c) (d) The Registered Persons must ensure that: The main ground floor lounge is fully re-decorated and updated. The ground and first floor hallways are fully re-decorated and updated. The ceilings in rooms 17 & 19 are re-decorated. 17th June 2005 8. 19 23 (2) (b) (c) (d) The Registered Persons must ensure that: The carpet in the ground floor lounge is replaced. The carpet in the first floor hallway is replaced. 17th June 2005 Hazlewell G54-G54 S19097 Hazlewell V221707 140405 Stage 4.doc Version 1.20 Page 25 The carpet in rooms 17 & 18 is replaced. 9. 20 23 (2) (o) The Registered Persons must ensure that the garage is kept locked at all times. The garden area must be kept clear of old / broken equipment (Previous timescale of 30/11/04 not fully met) The Registered Persons must ensure that the grab / support rail located in the ground floor toilet is made secure. 1st May 2005 10. 21 13 (4) 1st June 2005 11. 21 23 (2) (J) (Previous timescale of 18/09/04 not met) The Registered Persons must 1st July ensure that suitable adapted 2005 bath / accessible shower facilities are provided on both upper floors of the home. (Previous timescale of 18/09/04 not met) The Registered Persons must ensure that the stair lift in place is either fully serviced or removed. (Previous timescale of 30/11/04 not met) The Registered Persons must ensure that residents bedrooms are not used for the storage of equipment. (Previous timescale of 18/10/04 not met) The Registered Persons must ensure that suitable shading be fitted within the conservatory area so that it may be utilised by residents comfortably at all times. 12. 22 23 (2) 1st June 2005 13. 22 23 (2) (l) 1st May 2005 14. 25 23 (2) (g) 29th April 2005 Hazlewell G54-G54 S19097 Hazlewell V221707 140405 Stage 4.doc Version 1.20 Page 26 15. 26 23 (2) (d) (Immediate Requirement issued 15.04.05) The Registered Persons must ensure that the sluice room is refurbished. This area must be kept in a clean and hygenic state at all times. (Previous timescale of 30/11/04 not met) The Registered Persons must ensure that Criminal Records Bureau (CRB) disclosures are obtained for any persons working at the home on a regular basis. This is with particular reference to the domestic staff member / maintenance person. The Registered Persons must ensure that the individual records of training are fully compiled and kept up to date. The Registered Persons must ensure that all new staff receive induction training to sector skills specification within six weeks of employment. Full records must be maintained to evidence this. The Registered Persons must ensure that the home is managed with sufficient care, competence and skill. 1st July 2005 16. 29 7,9,19 1st June 2005 17. 30 18 (1) 1st May 2005 1st July 2005 18. 30 18 (1) 19. 31 10 (1) 1st June 2005 20. 33 24 Suitable administrative / support staff must be provided to ensure this. 1st July The Registered Persons must ensure that an annual 2005 development plan be put in place for the home. This must reflect the views of residents, their representatives and other stakeholders in the Hazlewell G54-G54 S19097 Hazlewell V221707 140405 Stage 4.doc Version 1.20 Page 27 service. 21. 36 18 (2) The Registered Persons must ensure that all care staff receive 1-1 supervision at least six times annually. (Pro-rata for part-time staff). Persons giving supervision must be appropriately trained to do so. 22. 38 13 (4) The Registered Persons must ensure that the issues as identified by the Fire Officer in February 2005 are fully addressed. (Immediate Requirement issued 15.04.05) The Registered Persons must ensure that all potentially hazardous substances are securely stored at all times. The Registered Persons msut ensure that footplates are used on wheelchairs at all times. (Previous timescale of 30/09/04 not met) The Registered Persons must ensure that the CSCI is notified of all events adversely affecting the well-being of residents. (Previous timescale of 30/09/04 not fully met) 29th April 2005 1st July 2005 23. 38 13 (4) 1st May 2005 1st May 2005 24. 38 13 (4) 25. 38 37 1st May 2005 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. Hazlewell Refer to Standard 11 Good Practice Recommendations Individual wishes regarding arrangements following death G54-G54 S19097 Hazlewell V221707 140405 Stage 4.doc Version 1.20 Page 28 2. 3. 4. 22 30 should be obtained and recorded. Where a resident declines to discuss these details, this should be documented as such. It is recommended that an electric hoist be purchased for use at the home. It is strongly recommended that staff meetings take place every two months as a minimum. Hazlewell G54-G54 S19097 Hazlewell V221707 140405 Stage 4.doc Version 1.20 Page 29 Commission for Social Care Inspection Ground Floor - CSCI 41-47 Hartfield Road Wimbledon SW19 3RG 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. 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