Inspection on 02/06/09 for Hazlewell

This inspection was carried out on 2nd June 2009.

CQC found this care home to be providing an Adequate service.

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

Other inspections for this house

Hazlewell 03/03/10

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 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 06/08/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE Hazlewell 29-31 Hazlewell Road Putney London SW15 6LT Lead Inspector Sharon Newman Key Unannounced Inspection 11th May 2009 09:00 DS0000019097.V375228.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Hazlewell DS0000019097.V375228.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Hazlewell DS0000019097.V375228.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 Old age, not falling within any other category registration, with number (29) of places Hazlewell DS0000019097.V375228.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing - Code N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. 3. Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 29 There shall be no further admissions of service users to Hazlewell without prior written agreement of the Care Quality Commission. 18th, 19th and 22nd December Date of last inspection Brief Description of the Service: Hazlewell is a 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 fees are £650.00 per week. Hazlewell DS0000019097.V375228.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. As part of the inspection of this service we visited the home over two days. On the first day (11th May 2009) the Pharmacy Inspector carried out an inspection of the medication systems at the home. On the second day (2nd June 2009) a Regulation Inspector was accompanied by a Local Area Manager, where time was spent talking to staff, residents and viewing paperwork. A tour of the premises was carried out and care records were looked at. The visits to the service involved looking at their compliance with Statutory Enforcement Notices served by the CQC (formally CSCI) to address noncompliance issues found at the service during the previous inspection. An Annual Quality Assurance Assessment (AQAA) which is a self-audit of the service was completed by the manager before our visit to the home. At the time of the inspection thirteen residents were living at the home. We did find some improvement at this service on this visit and the quality rating has therefore increased from 0 stars to 1 star. However, we will be monitoring progress at this home to ensure that the improvements made are sustained and further progress is made to ensure that national minimum standards are met. What the service does well: The staff and the manager were seen to have a good rapport with the residents. Staff demonstrate a caring attitude towards the residents. The home is clean and the environment looks more homely. Complaints are taken seriously and followed up. What has improved since the last inspection? Their have been improvements to the environment of the home including new carpets, new furniture and re-decoration to areas of the home. The conservatory now has blinds fitted to the windows to help keep this area more shaded for residents. Hazlewell DS0000019097.V375228.R01.S.doc Version 5.2 Page 6 The information in the residents care plans continues to improve and the manager has added information relating to the Mental Capacity Act. The fire extinguishers have been serviced. Health and safety documentation including that relating to portable appliance testing and gas safety was up to date. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Hazlewell DS0000019097.V375228.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.V375228.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3, 6 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live at the home have their needs assessed and kept under review to ensure relevant care is provided. EVIDENCE: The home has not been admitting anyone to the home as a condition was imposed that: No further admission should be made without prior written agreement of the Commission for Social Care Inspection (Now Care Quality Commission). The manager told us that any potential new residents to the home would be invited to visit the home. The manager reported that she would go to assess any prospective resident to help to ensure that the home can meet their needs. Hazlewell DS0000019097.V375228.R01.S.doc Version 5.2 Page 9 The local authority re-assesses the needs of the people living at the service to ensure the care plans match their current needs. The care plans we looked at continue to be evaluated monthly to ensure that they are relevant. There is an information pack in each residents room providing information about the service offered. A service user guide and statement of purpose have been drawn up for residents. However we discussed with the manager that these could be improved with use of large print and pictures to make them easier to read and understand. Intermediate care is not provided at the service. Hazlewell DS0000019097.V375228.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The care planning system helps ensure that resident’s needs are met. Residents have access to health and social care professionals. However, medication systems and practices at the home do not ensure that medicines are handled, administered or recorded appropriately and safely to the residents. Residents are treated with respect. EVIDENCE: The residents plans that we looked at were detailed and informative. They contained information including personal history’s and likes and dislikes. As found at the previous inspection the care plans are individualised to the needs and wishes of each person who lives at the home. In those looked at the Hazlewell DS0000019097.V375228.R01.S.doc Version 5.2 Page 11 resident or their representative has signed the care plan to show their agreement with the care to be provided. There is also information relating to the Mental Capacity Act to show that staff have considered this important information when planning care for individuals. Monthly weight checks continue to be carried out on each person living at the home and risk assessments were seen covering areas such as continence, use of ‘cot-sides’ (bed rails) and moving and handling. Evidence that staff have received training in diabetes care, palliative care and continence care was seen in some staff files of trained nurses. The manager continues to maintain good links with relevant health and social care professionals in the community so that she can access their support and advice on relevant care issues. As stated in the previous inspection report the recording in the daily notes could be developed further to give more of a picture of how the resident has spent their day, what they have done, food consumed, and interactions they have had. The terms currently still used, such as ‘…washed and dressed…’ and ‘…ate well…’ do not show this. Staff were observed to speak to and treat residents with dignity and respect and to know on their bedroom doors before entering the room. Below is the report from Pharmacist visit to the service on 11/05/09: We carried out an inspection of medication to check compliance with a Statutory Requirement Notice issued on 07/08/08. The notice of 07/08/08 required that the home ensures arrangements are in place for the recording, handling, safe keeping, safe administration and disposal of medication received into the home. We audited medication in each unit by checking stock held against recording on the Medication Administration Record (MAR). We found overall that records on the MAR were tidy and complete. There were records of receipts on the MAR and a separate record for disposal of medication which was via a licence waste carrier. We found that there were some gaps on just one resident MAR which were for single doses of eye drops, an ear spray and a tablet. The tablet was not in the blister pack therefore we assumed that it was given but not signed for. We counted tablets which were in their original packs to see if the balance could be reconciled with signatures for administration. We found that balances of calcium tablets could not be reconciled for 2 residents. There were 3 and 8 too many tablets left which could mean that the medicine were not given but signed as given. There was one too many mirtazepine for one resident and one Hazlewell DS0000019097.V375228.R01.S.doc Version 5.2 Page 12 too few for another. There were 4 too many sachets of a medicine for osteoporosis for another resident. Some of the audits were accurate. For example a resident was prescribed iron tablets mid cycle and the balance was correct. A weekly tablet for osteoporosis was given correctly for three residents. There was an improvement in the recording of variable doses of paracetamol. This same good practice needs applying to other medicine such as senokot and salbutamol nebules which were both prescribed as one or two. We were unable to audit the paracetamol for one resident because the records showed that 24 tablets had been received but there were signatures for 35 given and 5 tablets were left. One resident was prescribed an antibiotic to be given four times a day for 5 days. We counted 21 signatures which means that one dose was not given but signed as given. Another resident prescribed an antibiotic did not have their simvastatin restarted when the course finished. This was requested by the GP. We checked controlled dugs and balances were correct. The fridge temperature was satisfactory although the fridge required defrosting. The home did not have a current BNF only one dated 2006. The lancets in use for blood glucose testing were not of the professional type to prevent the risk of infection. We were pleased that the home was submitting audits as requested but these need to be expanded to ensure that the records are accurate. The home had received training on 4/3/09 and another trainer was carrying out a further session on 2/6/09. The homes policy had still not been updated. We judged therefore that the home is making progress but does not fully comply with the statutory requirement notice. Auditing processes need to be more robust to provide us with the evidence that medication is managed safely. A warning letter has been sent the Registered provider of this service regarding the medication issues highlighted above. Hazlewell DS0000019097.V375228.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents have the opportunity to be involved in some activities provided by the service. Residents have a choice of wholesome home-cooked food daily. EVIDENCE: The manager told us that she is going to arrange a garden party during the summer months. She said that a concert was held three weeks ago at the home, aromatherapy sessions are arranged for residents and a ‘colouring lady’ visits. She also said that a curate from a church visits the home. A resident wrote “they put on lovely records – both music and song and it is great. They also engage a music man with a beautiful Yamaha organ and off we go singing. We enjoy it so much every month.” They also told us: “there are no restrictions here. We are free to say and do what we like…….. we can have as many visitors as we want and they are always offered refreshments.” Hazlewell DS0000019097.V375228.R01.S.doc Version 5.2 Page 14 The service does not currently offer any residents meetings. We discussed with the manager that residents should be offered the choice of having small meetings or discussion groups. This is to enable them to voice their opinions about the home and any changes they may like. As stated in the previous report “further work could be done in this area to ensure that people living at the home are more involved in the community or more structured daily activities within the home, eg. arts and crafts, book reading, flower arranging, bingo, card games or conversation groups.” The manager writes in her AQAA that she plans to put “memory boards and photographs in residents rooms.” Staff will compile these in collaboration with the residents. The manager told us in her AQAA that “menus are varied on a weekly basis and we serve good homely food but choice within reason is always given.” Given. Residents spoken to reported that the food was “good.” The food was seen to be cooked freshly each meal time and choice given. They also told us that they have visitors who are made welcome. A resident told us that they “love it here.” Hazlewell DS0000019097.V375228.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are systems in place to deal with complaints. Complaints are taken seriously and responded to. Many staff have now received training in the safeguarding of vulnerable adults. EVIDENCE: The manager told us that fifteen staff members have now attended the updated safeguarding vulnerable adults (SOVA) training. She reported that this training was provided by a representative from the London Borough of Wandsworth who came to the home to offer this training. This helps to ensure that staff are aware of their responsibilities in this area. We saw certificates in some staff files to demonstrate this. However, we discussed with the manager that copies of these certificates need to be available at the home for all staff. The manager sent us some more evidence to support that staff have attended SOVA training following the inspection. A complaints procedure is in place and will need to contain the contact details for the new commission (CQC). Full details of a recent complaint were seen and the home has involved the relevant professionals from the London Borough of Wandworth. They have also drawn up an action plan following this Hazlewell DS0000019097.V375228.R01.S.doc Version 5.2 Page 16 complaint. This demonstrates openness and willingness to involve outside help to ensure that the complaints is fully looked into. Hazlewell DS0000019097.V375228.R01.S.doc Version 5.2 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. This area is improving and the service now looks more homely and attractive. The home is clean and hygienic. EVIDENCE: At this inspection we have found that improvements have been made to the environment. New furniture has been purchased and new carpets have been laid. Blinds have been added to the conservatory windows to help keep this area cooler. The service looked more homely and comfortable. On the ground floor there is a large sitting room area, that was clean and tidy leading out on to a spacious conservatory with views over the garden. Hazlewell DS0000019097.V375228.R01.S.doc Version 5.2 Page 18 There is now a bathroom on the top floor of the home. This helps to ensure that residents do not have to travel between floors to wash. The kitchen was clean, however some doors and drawers did not have handles and these must be replaced. We also saw that one radiator on the ground floor still requires painting and an area in one of the toilets on the ground floor requires plastering. Some old furniture had been stored in the garden and this must be removed. The home was clean and hygienic at the time of inspection. Hazlewell DS0000019097.V375228.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff display a caring attitude to residents. Staff training is improving which helps to ensure that staff can carry out their roles, however more documentary evidence of this is needed. Appropriate recruitment practices are in place to help to ensure the safety of the residents. EVIDENCE: We observed that the interaction between the staff and residents was caring and respectful. Staff told us that they felt the environment was much improved and the building was looking ‘nice’. One staff member wrote: “my induction covered everything, and after that I did all the relevant training, courses and workshops to get better knowledge and skills. I receive very good training here.” They also reported that they have “monthly meetings.” Hazlewell DS0000019097.V375228.R01.S.doc Version 5.2 Page 20 Another wrote: “Staff work together as a team to make sure residents are given the best care.” A staff member told us that the registered owner visits the home to talk to them. During this inspection we looked at four staff files, which were found to contain appropriate information regarding their recruitment, such as proof of identification, evidence of a Criminal Records Bureau check, two references and record of the interview of staff. Staff do not have a contract for their employment at the service. Staff meetings are held monthly to allow staff to keep up to date and to raise any issues. Meeting minutes are kept at the home to provide evidence of these meetings. The minute of the last meeting were not available and the manager sent them to us to show that it had taken place. Staff training is taking place and there is a chart on the office wall to indicate what training staff have attended. However, staff do need to provide copies of their certificates to the service to ensure that there is evidence of their attendance at the training. We found that there was not enough evidence to show that staff are up-to-date with moving and handling training and this must be put in place. This is to ensure that residents are not put at risk from poor moving and handling techniques. As stated in the previous inspection report: “The service does not promote a modern working environment for staff, or promote up-to-date ways of working with residents to improve their care, health and welfare. This is because there are no computer or internet facilities at the home to enable staff to access resources and keep up-to-date with relevant guidance, policies, procedures and legislation relating to their work. There are no photocopy facilities at the home.” Hazlewell DS0000019097.V375228.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager is experienced and caring. Their have been improvements at this service since the previous inspection of the home. Quality assurance systems are in place to help ensure that residents views are taken into account, however more needs to be done in this area such as the introduction of residents meetings. EVIDENCE: Hazlewell DS0000019097.V375228.R01.S.doc Version 5.2 Page 22 The manager was present for the inspection and was seen to have a genuine and warm attitude towards the residents. A staff member wrote: “Matron is a very supportive manager.” Another wrote: “my manager is very supportive.” A further staff member commented: “Our matron is very helpful and kind to the patients and staff and meets all their needs.” A health and social care professional spoken to reported that several changes have taken place since our last inspection including some refurbishment of the home. They feel that the home offers an “old fashioned caring environment.” A quality assurance programme is in place to help ensure that care within the home is audited. We discussed with the manager that residents meetings or discussion groups should be held to help involve them in the running of their home. The manager carries out regular audits of health and safety hazards around the home. Medication audits are carried out three monthly by the pharmacist who supplies medication to the home. There is a safe at the home where resident’s valuables and money can be stored. The manager told us that one London Borough Council is writing cheques meant for the use of two residents in her name, she is then using this money to purchase items for the two residents. However, we explained to her that this is unacceptable and this practice must stop. She reported that she will speak to the council to ensure that this does not happen again. We also discussed with the manager that the policies and procedures at the home need to be regularly reviewed, signed and dated. There was evidence at the home that the Registered Provider’s visits to the home (Regulation 26 visits) are taking place so that the Provider is auditing care and systems in place at the home on a monthly basis. Health and safety checks have improved since the last inspection. We saw evidence to show that the fire extinguishers have been checked. Also, fire drills are documented and the gas safety and portable appliance testing paperwork were in place. These measures help to ensure the safety of the residents. Information including the last staff meeting minutes, the medication audit for May 2009, information on staff safeguarding training and staff training certificates was requested at the time of inspection. This was sent to us, as requested following the inspection. The manager writes in her AQAA that “we have done our best to comply with CSCI inspection report recommendations. Staff have taken more relevant training courses throughout the year and a comprehensive refurbishment programme has taken place with a generous grant from Wandsworth Council.” Hazlewell DS0000019097.V375228.R01.S.doc Version 5.2 Page 23 Hazlewell DS0000019097.V375228.R01.S.doc Version 5.2 Page 24 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 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 X X 3 Hazlewell DS0000019097.V375228.R01.S.doc Version 5.2 Page 25 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 OP9 Regulation 13(2) Requirement That the auditing process is developed to include checks of stock so that there is evidence that medicines are managed safely and the resident’s well being maintained. Audits must be sent to CQC monthly and must give the reason for discrepancies in recording and stock balances. This is the subject of a Warning Letter sent to the provider following this inspection. 2 OP9 13(2) The home must use professional lancets when sampling blood for glucose. This is to prevent the risk of blood borne infections. This is the subject of a Warning Letter sent to the provider following this inspection. The home must have a current BNF so staff can refer to information on medication and its uses and side effects. DS0000019097.V375228.R01.S.doc Timescale for action 01/07/09 01/07/09 3 OP9 13 (2) 01/08/09 Hazlewell Version 5.2 Page 26 4 OP12 16 (2) (m) 5 OP19 23 (2) (b) (c) (d) (j) The home must offer a wider range of structured activities to those living at the home. They must consult with the residents about what they would like to be offered. The rubbish and old furniture stored in the garden must be removed. The radiator on the ground floor must be painted. The area in the ground floor toilet that requires plastering must be completed. Copies of certificates to evidence all training undertaken by staff must be kept at the home. Previous timescale of 31/01/09 not met All staff must receive up-to-date training in moving and handling to help to ensure the safety of the residents. Residents monies must be paid directly to them and made out in their name. 01/10/09 01/07/09 6 OP30 18 01/09/09 7 OP30 18 01/10/09 8 OP35 16(2)(l), Sch 4 (9) 01/07/09 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 OP3 Good Practice Recommendations The service should consider updating the Service User Guide and Statement of Purpose so that they are available in large print and also contain pictures to ensure that they are easier for service users to read. The homes medication policy and procedure should be updated and typed and all old procedures archived. DS0000019097.V375228.R01.S.doc Version 5.2 Page 27 2 OP9 Hazlewell 3 4 OP18 OP33 All staff should receive up-to-date training in abuse awareness issues. 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.V375228.R01.S.doc Version 5.2 Page 28 Care Quality Commission London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Hazlewell DS0000019097.V375228.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!