Inspection on 16/07/07 for Hazlewell

This inspection was carried out on 16th July 2007.

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 21/04/06

Hazlewell 26/08/05

Hazlewell 14/04/05

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 Sharon Newman Unannounced Inspection 16th July 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Hazlewell DS0000019097.V342709.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Hazlewell DS0000019097.V342709.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hazlewell Address 29-31 Hazlewell Road Putney London SW15 6LT Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8788 8753 020 8248 5954 Mr D Patel Rosemary Carmen Molloy Care Home 29 Category(ies) of Dementia - over 65 years of age (2), Old age, registration, with number not falling within any other category (29) of places Hazlewell DS0000019097.V342709.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Dementia The home may provide accommodation and care for two named service users with dementia. The category DE(E) must be removed once these named service users are no longer accommodated. 21st April 2006 Date of last inspection Brief Description of the Service: Hazlewell is a twenty-nine bedded care home providing nursing care for older people. The property consists of two semi-detached Victorian houses that have been joined together to make one home. The home is on three storeys and has been extended to the rear with a large conservatory. There is a large rear garden with a patio area available. Hazlewell is situated in a quiet residential street reasonably close to available shops and transport links in Putney. Information about the home is provided to residents in a written guide. The current range of fees are £474.00 to £650.00 per week. Hazlewell DS0000019097.V342709.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection of this service included an unannounced visit to the home on 16th July 2007 by one regulation inspector. The manager was not on duty on the day of the visit. However, the deputy manager was present and the inspector spoke to him at length, some residents were also spoken to. The registered provider also came to the home on the day of inspection to introduce himself. The manager was spoken to by telephone after this visit. Documentation looked at included medication records, staff recruitment information, residents care plans and health and safety documentation. A tour was also taken of the premises. The manager is completing an Annual Quality Assurance Assessment (AQAA) which is a self assessment survey. This was not received before completion of this report. Surveys were left at the home for residents, staff, relatives and health professionals to complete. None were returned prior to completion of this report. What the service does well: What has improved since the last inspection? What they could do better: There are many areas in which this home could improve and these are documented in the main body of the report. Some areas needing particular improvement include the care planning system, wound care recording and the daily recording of information about residents. Hazlewell DS0000019097.V342709.R01.S.doc Version 5.2 Page 6 More activities need to be offered to residents at this home and this includes offering a range of external activities for those residents who would like to participate in life outside the home. Staff training in areas such as wound care and continence care need to take place to ensure that they are up-to-date with current good practice in these areas and that residents are not placed at risk. Particular attention needs to be given to improving the environment at this home which is poor in many areas. This is documented in the ‘Environment’ section of this report. Up-to-date Safeguarding Adult Guidelines need to be obtained from the London Borough of Wandsworth and staff need to have training in this area. The home needs to ensure that health and safety issues are addressed and that the home has all of the correct documentation in place. This is to help make sure that residents and staff are not placed at risk. 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. Hazlewell DS0000019097.V342709.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hazlewell DS0000019097.V342709.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The needs of residents are assessed prior to admission to make sure that the home can meet these. The written guide for residents needs updating to provide good information to residents. EVIDENCE: Assessments were seen to be in place for five residents whose files were looked at. The deputy manager reported that the manager carries out an assessment of potential residents needs prior to them coning to the home. Assessments were also seen to be carried out by Wandsworth Social Services for those residents placed through the London Borough of Wandsworth. There was not evidence to demonstrate that the residents guide has been updated. Staff on duty were not sure whether this had occurred. A guide seen Hazlewell DS0000019097.V342709.R01.S.doc Version 5.2 Page 9 on the day of inspection contained out-of date information. As stated in the previous inspection report: This document currently includes out of date information about making complaints and ‘a typical day’ at the home. The guide must also accurately state the choice on offer to residents at mealtimes. Hazlewell DS0000019097.V342709.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The care plans are not person centred and there is not enough information to demonstrate that health care needs are fully met. There is not enough evidence to show that staff have received up-to-date training in areas that affect the health of the residents including wound care, continence care or diabetes care. EVIDENCE: A health/social care professional commented that the home provided ‘individual person centred care’ but that ‘clearer care planning documentation’ would benefit the home. Whilst some of the information in the care plans was detailed other information needed more detail. Wound care information was inconsistent. One individual had wound care assessment charts in place whilst another’s could not be Hazlewell DS0000019097.V342709.R01.S.doc Version 5.2 Page 11 found. Those that were in place were being kept loose in a folder and would benefit from being better organised. There was no evidence of visits from a Tissue Viability Nurse, although the manager did say that representatives from wound care companies visit the home to give advice. However, the home should attempt to make contact with the Tissue Viability Nurse at the local Primary Care Trust for advice about wounds and pressure sores. No wound photos were seen in residents files which help to chart the progress of wounds and these must be put in place. Residents permission for this must be sought and evidence kept of this. One wound care plan was detailed, however another wound care plan should have been re- written as it did not reflect the residents’ current needs. Care plans need to be up-to-date and reflect the care that needs to be given so that staff can follow them and meet the needs of the residents. A staff member reported that they had not received recent training in wound care, diabetes care or continence care. The home must ensure that all staff involved in wound care (especially nursing staff) have received up-to-date training in this area to ensure that they are aware of current best practice. They must also be aware of the current best practice guidelines in relation to wound care from the National Institute of Clinical Excellence (NICE) and the local PCT. An entry in one care plan stated ‘doubly incontinent’ but there was no indication as to whether a continence specialist was involved in their care or assessment. Information needs to be clear and where needs have been highlighted the appropriate action must be documented. The care plans did not demonstrate the involvement of the residents and need to be more person centred. Evidence was seen of GP visits to individual residents. The medication cupboard was seen to be locked securely on the day of inspection. No omissions were seen on the medication administration records that were looked at. However one did not contain a completed allergy section. All allergy sections must be fully completed to ensure that residents are not placed at risk. Where there are no allergies known then this must be documented. Hazlewell DS0000019097.V342709.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Activity provision is limited and only some activities meet the needs of the people who live here. Residents are able to maintain contact with family and friends. EVIDENCE: No arranged activities were seen to take place during the visit. Many residents were seen to be sleeping in their chairs or staring ahead of them. In response to questions about what activities are arranged for residents a staff member remarked ‘sometimes we get them to stamp their feet and clap their hands in time to music.’ There was no evidence that external activities are arranged for residents. Those residents spoken to reported that they were not taken out of the home. One resident said that they would like to visit the pub occasionally; they are only able to do this if taken by a relative. One staff member reported that ‘the Hazlewell DS0000019097.V342709.R01.S.doc Version 5.2 Page 13 only time residents go out of the home is to go to hospital visits.’ The home must look at ways of improving activity provision for the residents. One resident said ‘oh we don’t do much here’ another said ‘we just sit in our chairs most of the time.’ A health/social care professional commented that an ‘activities co-ordinator would be beneficial’ to the residents. A relative reported that they were free to visit the home when they wished. Many residents commented favourably on the food and said that the food was good. Staff were observed to support residents to eat their lunch. However, a relative commented on the lack of fresh fruit for residents and it was seen that there was no fruit on offer during the visit. This must be made available to residents. A health/social care professional wrote that residents tell them that the food provided could be better and ‘the menus could be improved.’ Hazlewell DS0000019097.V342709.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The complaints procedure that is supplied to residents on admission to the home needs updating. There is insufficient evidence to demonstrate that staff are up-to-date with the new Wandsworth Safeguarding Adults Procedures and this may present a risk to residents. EVIDENCE: As found at the previous inspection visit the home keeps a record of complaints however as stated in the previous inspection report: the complaints procedure contained in the guide for residents requires updating as this incorrectly references other authorities that are no longer in existence. This requirement remains outstanding. An out of date complaints procedure was seen hanging in a residents bedroom. An up-to-date copy of the new Wandsworth Safeguarding Adults Procedures (SOVA) could not be found in the home on the day of inspection. Also, staff spoken to were unaware of these new procedures. The home must ensure that it obtains a copy of these procedures and that staff receive training in the updated SOVA procedures. This is to help ensure that residents are not placed at risk. Hazlewell DS0000019097.V342709.R01.S.doc Version 5.2 Page 15 A resident who had bed rails in place did not have a risk assessment for these in their care plan and this must be carried out. The home must also seek the agreement of the residents and/or their relatives and relevant health and social care representatives. Poor maintenance at the home may present a health and safety risk to residents and carpets that are not secured properly and that are raising away from the floor could present a trip hazard. Hazlewell DS0000019097.V342709.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 26 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. There are still many areas that require improvement. This service does not present as homely due to the environment which looks tired, shabby and dated. This home is poorly maintained and decorated. The staff try their best to maintain standards of cleanliness within a poor environment. EVIDENCE: There are many areas that need to be addressed regarding the environment and requirements from previous inspection visits have still not been met. Many carpets throughout the home look dirty and marked, despite being informed Hazlewell DS0000019097.V342709.R01.S.doc Version 5.2 Page 17 that they are regularly washed. Some of the carpets in the bedrooms do not completely cover the floor and look unsightly. Some carpets may present a trip hazard to residents, visitors and staff as they are peeling away from the floor. Paintwork throughout the home is peeling and some walls are stained with brown marks. One resident said ‘I know the decoration isn’t up to much but you can’t have everything I suppose.’ The beds in many of the bedrooms throughout the home are very old fashioned and make the home feel institutional. These need to be replaced. This issues has been raised by inspectors at previous inspection visits. Some of the residents bedrooms are personalised with pictures, plants and photographs, however many looked bare with minimal attempts made to personalise them. One bedroom contained two beds, one of which had equipment on top of it. It looked like a storage room. The inspector was informed that this room was actually being used. Bedrooms must not present like this as it demonstrates a lack of respect for residents dignity. Storage throughout the home appeared to be a problem as wheelchairs, mattresses and bed equipment was stored in communal areas throughout the home. The registered provider reported that there was ‘not enough space at the home.’ The top floor bathroom is still not working. This facility would benefit from being turned into an adapted shower or bath for the residents use. At present residents have to be taken down to the next floor for a shower. The broken bath panel needs to be fixed. The lounge of the home was decorated in 2005 and is now starting to show signs of wear and tear as the wallpaper is peeling in some sections and there is cracked paintwork near the conservatory entrance. Some chairs have been replaced, however there are other chairs throughout the home that require replacement as they are stained, greasy and some are torn in places. The seating on some of the chairs does not match the chair itself and this again makes the home look institutionalised. Although the inspector was told that there have been improvements to the garden on the day of inspection there were still many weeds in the garden and the storage of garden furniture looked unsightly. One resident remarked ‘still weeds can be quite pretty sometimes.’ The inspector was informed that a voluntary person visits the home and looks after the pot plants in the garden, these do look attractive and residents commented favourably about them. Hazlewell DS0000019097.V342709.R01.S.doc Version 5.2 Page 18 Although the home was clean on the day of inspection it is to the credit of the staff that they are able to maintain levels of cleanliness despite the internal condition of the home. The registered provider reported that the home would be receiving a grant to help with the decoration of the home. The Commission for Social Care Inspection was informed following the inspection visit that parts of the ceiling in one resident’s room fell down causing abrasions to the resident concerned. This is totally unacceptable and the registered provider must ensure that this home provides a safe environment for residents to live in. A health/social care professional wrote that ‘the environment and decorative standard of the home could be vastly improved.’ Hazlewell DS0000019097.V342709.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Staff are appropriately trained to help ensure that they can carry out their roles. They are also receiving one-to-one supervision to help support them in their roles. Staff files do not all contain evidence of necessary recruitment checks to prevent residents being placed at risk. EVIDENCE: Some staff at the home were observed to behave in a courteous and professional manner. They help to create a friendly atmosphere at the home. Residents spoke highly of the staff and one said that they were ‘very kind.’ The acting manager reported that there were enough members of staff to meet the needs of the residents. Staff reported that as resident occupancy levels have dropped at the home the provider has decreased the amount of staff working at the service. However, the home needs to ensure that it provides enough staff to enable residents to be taken out to access activities and services in the wider community. There was evidence of a staff training programme and the deputy manager reported that they are trying to ensure that staff are up-to-date in mandatory Hazlewell DS0000019097.V342709.R01.S.doc Version 5.2 Page 20 areas including: moving and handling, first aid, health and safety and food hygiene. Four staff recruitment files were looked at and there was evidence that most necessary pre-employment checks are carried out. However a Criminal Record Bureau Check (CRB) could not be found for one individual and the CRB check list within the home stated that it was ‘mislaid.’ Evidence of CRB checks must be kept at the home to help ensure that residents are not placed at risk. Hazlewell DS0000019097.V342709.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There are many areas that require improvement throughout the home The manager is well-liked at the home by residents. There is insufficient evidence to demonstrate that adequate health and safety checks are being carried out at the home. The home has old fashioned facilities in terms of office equipment. Audits have not been compiled into adequate quality assurance reports and there is no evidence to suggest how findings have been addressed. EVIDENCE: Hazlewell DS0000019097.V342709.R01.S.doc Version 5.2 Page 22 The manager was not on duty on the day of inspection, however staff and residents spoke highly of her. One resident said she is ‘so lovely’ and a staff member reported that she is ‘really excellent and very supportive.’ The deputy manager was very helpful and professional throughout the visit and displayed a very caring attitude to the residents. The inspector was informed that there are no computer facilities at the home. It is recommended that these are installed so that staff can access up-to-date health and social care information that will be of benefit to the residents health and safety. Staff would also benefit from access to the CSCI website for advice and information and from email to work efficiently with other professionals and organisations for the benefit of the residents. There are also no photocopy facilities at the home. Evidence was seen that quality assurance is carried out to help gain the views of the residents and relatives. Medication audits and care plan audits are also carried out throughout the year. However, there was no evidence to show how the information has been collated and shared with the respondents, or if any changes have been made as a consequence of the quality assurance. This must be carried out. An annual quality assurance audit (AQAA) was sent to the home by the CSCI for completion but was not returned before this reported was finished. This is a legal requirement and must be completed. Staff one-to-one supervision is now taking place more regularly and helps ensure that staff have the direction and support that they need to carry out their roles. And for any training and development needs to be identified. There was insufficient evidence that checks relating to health and safety including portable appliance testing, electrical installation checks, gas safety and legionella were up-to-date. Up-to-date certificates for all these areas need to be obtained to help ensure the safety of the residents and staff. Hazlewell DS0000019097.V342709.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 x 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 1 1 X 2 X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 1 Hazlewell DS0000019097.V342709.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 5 (1) Requirement The information in the Residents Guide must be accurate and up to date. This is to ensure that residents have an informed choice when they are deciding whether to come to this home. Previous timescales of 01/08/06 and 01/01/07 not met. The following must be addressed: Individual care plans must fully address health, personal and social care needs of residents. Daily care notes must be completed in line with NMC guidelines. Previous timescales of 01/08/06 and 01/02/07 not met. Full and detailed assessment documentation must be put in place for all wounds and pressure sores as required for individual residents. These must include a detailed plan of care for care staff to Hazlewell DS0000019097.V342709.R01.S.doc Version 5.2 Page 25 Timescale for action 01/09/07 2 OP7 12 (1)15 01/09/07 3 OP8 12(1) (b)15 (2)17 (1) (a) 01/09/07 follow. Photographs must also be put in place to document the progress of the wound. All staff involved in wound care must receive up-to-date training. To ensure that residents needs are met in this area and they receive the most up-to-date care. All staff involved in the continence care and assessment of residents must receive training in this area. To ensure that residents needs are met in this area and they receive the most up-to-date care. All staff involved in the care and assessment of residents with diabetes must receive training in this area. To ensure that residents needs are met in this area and they receive the most up-to-date care. The Registered Persons must ensure that all items of medication (including creams) be securely stored at all times. Previous timescales of 01/11/06 and 01/05/06 not met. The allergy section of the medication administration records must be fully completed. A full programme of activities 01/10/07 must be put in place at the home based on the individual preferences of residents. Previous timescales of 01/08/06 and 01/01/07 not met. Any activity programme provided 01/10/07 must enable residents to engage in local, social and community activities. Residents must be given the 16/07/07 DS0000019097.V342709.R01.S.doc Version 5.2 Page 26 4 OP8 18 (1) 01/09/07 5 OP8 18 (1) 01/09/07 6 OP8 18 (1) 01/09/07 7 OP9 13 (2) (4) 16/07/07 8 OP12 16 (2) (m) (n) 9 OP13 16 (2) (m) (n) 12 (4) 10 Hazlewell OP12 choice to participate in a full range of activities and their choices documented. The home must show how it is meeting these needs. A choice of fresh fruit must be offered to residents daily. The complaints procedures for the home must include the correct contact details for the CSCI. All copies displayed at the home must be updated with this information. Previous timescale of 01/11/06 not met. The up-to-date procedures for the safeguarding of adults (SOVA) must be obtained from the London Borough of Wandsworth and staff must demonstrate that they have received training in these updated procedures. Risk assessments must be in place for the use of bed rail equipment and these must be signed by a relative/the resident and demonstrate that relevant health and social care professionals have been involved in this decision. The following must be addressed to ensure the comfort of the residents: The ceiling in room 22 must be decorated The bed in room 10 must be replaced, Worn or damaged chairs throughout the home must be replaced. Hazlewell DS0000019097.V342709.R01.S.doc Version 5.2 Page 27 11 OP16 22 (7) 01/09/07 12 OP18 13 (6) 01/09/07 13 OP18 13 (7) (8) 01/08/07 14 OP19 23 (2) (b) (c) (d) 01/10/07 The beds in rooms 3, 6, 16 and 22 must be replaced. Previous timescale of 01/01/07 not met. All those areas throughout the home needing redecoration must be decorated. The broken bath panel must be fixed. Adequate functioning bathroom facilities must be provided for residents on the second floor. These facilities must be in good working order. Previous timescales of 01/09/06 and 01/02/07 not met. Criminal Records Bureau (CRB) disclosures must be obtained for any persons working at the home. This is to help ensure that residents are protected by good recruitment practice. An annual development plan must be put in place for the home. This must reflect the views of residents, their representatives and other stakeholders in the service. Previous timescales of 01/08/06 and 01/01/07 not met. The Registered Provider must make monthly visits to the home and compile a written report as required by this Regulation. The written reports must be supplied to the home and to the CSCI on a monthly basis. All electrical appliances in use at DS0000019097.V342709.R01.S.doc 15 OP21 23 (2) (j) 01/10/07 16 OP29 7, 9, 19 01/08/07 17 OP33 24 01/10/07 18 OP33 26 01/08/07 19 Hazlewell OP38 13 (4) 01/08/07 Page 28 Version 5.2 the home must be tested for safety by a suitably qualified person. Full records must be kept to evidence this. Previous timescale of 01/01/07 not met. The Registered Persons must ensure that footplates are fitted to all wheelchairs in use at the home at all times. Previous timescale of 01/11/06 not met. Evidence that a gas safety inspection has taken place must be available at the home. Evidence that a legionella inspection has taken place must be available at the home. Evidence that a five yearly electrical installations check has taken place must be available at the home. 20 OP38 13 (4) 01/08/07 21 22 23 OP38 OP38 OP38 13 (4) 13 (4) 13 (4) 01/08/07 01/08/07 01/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations It is recommended that the systems for care planning be developed to make sure that good quality person centred information is recorded as required about areas such as life history and the individual’s likes and dislikes. It is strongly recommended that activities be provided by a dedicated member of staff. It is recommended that a walk-in shower be provided for residents on the second floor. The home should look at the possibility of holding regular DS0000019097.V342709.R01.S.doc Version 5.2 Page 29 2. 3. 4. Hazlewell OP12 OP21 OP33 residents meetings. 5 OP33 The home should consider installing a printer and computer facilities with internet access to improve communications at the home and to ensure staff can access up-to-date health and social care information that will benefit the residents. Hazlewell DS0000019097.V342709.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG 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 Hazlewell DS0000019097.V342709.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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