Inspection on 20/02/06 for The Hazelford Care Home

This inspection was carried out on 20th February 2006.

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

The Hazelford Care Home 18/03/08

The Hazelford Care Home 12/12/06

The Hazelford Care Home 01/09/04

The Hazelford Care Home 24/05/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE The Hazelford Care Home Boat Lane Bleasby Nottingham NG14 7FT Lead Inspector Steve Keeling Unannounced Inspection 20th February 2006 09:00 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 The Hazelford Care Home DS0000008689.V270162.R01.S.doc Version 5.1 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. The Hazelford Care Home DS0000008689.V270162.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Hazelford Care Home Address Boat Lane Bleasby Nottingham NG14 7FT 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) 01636 830 207 01636 830868 A.N.I. Healthcare Services Mrs Karen Marisa Cooper Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36) of places The Hazelford Care Home DS0000008689.V270162.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Date of last inspection 24th May 2005 Brief Description of the Service: Hazelford Residential home is owned by ANI healthcare services, and provides personal care and accommodation for 36 older people. The home is located on the outskirts of the village of Bleasby adjacent to the River Trent. There are minimal facilities in the village and the home does not have access to public transport. Local bus and train services are available from the village, about 1/2 mile walk away. The accommodation is arranged between two floors, has a purpose built ground floor extension and a conservatory. A passenger lift is provided, all bedrooms have en-suite facilities, and 34 bedrooms are single and one double room. The Hazelford Care Home DS0000008689.V270162.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over a 6-hour period and involved one inspector. The main method of inspection was case note tracking, this is a method of selecting service users within the home and discussing with them their expectations and experiences of living within the home environment. The case tracking method also analyses the records of the service users to ascertain if the service users identified needs are being addressed appropriately within the home setting and that their safety and well being is being maintained effectively. On this occasion two residents notes were case tracked. Also as part of the case tracking process a staff member within the home was informally interviewed to further evidence the quality of care afforded to the service users. At the time of the inspection a total of 30 residents were accommodated at the home. It was evident that the management and staff within the home are committed to providing a high standard of care for the service users. What the service does well: Assessments are completed on residents prior to admission to the home and it was evident that service users are provided with appropriate information in relation to the service provision. Service users spoken with at the time of the inspection were very complimentary in relation the care afforded to them at the home. The home is well maintained and decor is of a very high standard. It was evident that the handyman employed at the home ensures that both external and internal environments are, through appropriate interventions, safe and aesthetically pleasing for the service users. The Hazelford Care Home DS0000008689.V270162.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The Hazelford Care Home DS0000008689.V270162.R01.S.doc Version 5.1 Page 7 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Hazelford Care Home DS0000008689.V270162.R01.S.doc Version 5.1 Page 8 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 The Hazelford Care Home DS0000008689.V270162.R01.S.doc Version 5.1 Page 9 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 the following standard(s): 1. 6. Service users or their representatives receive appropriate information prior to admittance to the home so they can make an informed decisions as to the homes suitability in meeting the identified needs of the service users. The home does not provide intermediate care services. EVIDENCE: Service users or their representatives are given comprehensive information, in the form of a pamphlet and a “Statement of Purpose”, appertaining to the services provided at the home. The home’s statement of purpose now includes the homes complaints procedure thus satisfying a requirement from a previous inspection. It was evident that the information appertaining to the services and facilities at the home ensures that an informed decision can be made as to the suitability of the home in meeting the service users needs. The manager of the home stated that the home can also offer “trial periods” of residency of up to three month for service users to further establish the suitability of the home in meeting the needs of the service users. The Hazelford Care Home DS0000008689.V270162.R01.S.doc Version 5.1 Page 10 The Hazelford Care Home DS0000008689.V270162.R01.S.doc Version 5.1 Page 11 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 the following standard(s): 7. 8. 9. The case tracking procedure established that some care plans examined did not fully address the health needs of the service users and as such it could not be established that health needs were being fully met at the home. Two service users within the home are responsible for the administration of their own medication at the time of the inspection, although facilities for selfadministration of medicines are available it was established that no formal assessment process has taken place to establish the safety of the service users in performing this function. EVIDENCE: During the inspection on 24/5/05, a random selection of care plans were examined it was established that the care plans did not contain sufficient detail to guide staff in meeting service users assessed needs. It was evident that the care planning process, on occasions, lacks detail to guide staff in meeting service users needs. An examination of the moving and handling assessment within one case tracked service users documentation simply stated “bath hoist and frame” once The Hazelford Care Home DS0000008689.V270162.R01.S.doc Version 5.1 Page 12 again followed by a care plan that lacked sufficient details to inform care staff at the home. The mobility element of the assessment process stated “requires Zimmer” and the care plan stated that the service users requires assistance to mobilise up and down stairs, once again that care plan lacked specific detail to inform care staff at the home. The manager of the home confirmed that this element within the assessment and care planning process requires further development and it was established that she would be addressing the shortfalls in the near future in an attempt to establish a clear, concise and informative evaluation and care planning process. The Commission for Social Care Inspection will require an action plan which will, clearly identify how the identified shortfalls within the evaluation and care planning process will be addressed by 31/03/06 At the time of the inspection two service users were responsible for the selfadministration of medicines. It was established that should a service user wish to be independent in the administration of medicines lockable facilities are available within the service users rooms to promote safety. It was acknowledged that the manager had not performed a risk assessment on either of the independent self-administrators to ensure the two service users are safe in relation to the self-administration of medicines an as such the Commission for Social Care Inspection will require an action plan which clearly identifies how the identified shortfalls within this element of the assessment process will be addressed by 31/03/06. The Hazelford Care Home DS0000008689.V270162.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13. 14. Service users are encouraged to promote interactions within the broader community and service users family and friends can visit the home as they wish. EVIDENCE: The home has an activity co-ordinator employed three days a week. A range of ‘group’ activities and outings are available on a planned programme. Service users stated that the activities at the home are enjoyable and that they are always afforded a choice in relation to participation. It was also evident that service users have the choice as to when to retire to bed and when they wish to get up, one service user stated that if she fancied a “lazy morning” the staff at the home would always respect her wishes. A service users stated that it was more like a hotel that a residential home and she could not wish to be in a nicer place. In promoting interactions within the broader community the service users can utilise a car that is owned by the company to access areas of interest or shopping trips as they wish. The Hazelford Care Home DS0000008689.V270162.R01.S.doc Version 5.1 Page 14 It was evident that the home operates an “open door” policy in relation to visitations; service users stated that the staff at the home were always very friendly and respectful to visitors and went on to state that they were happy in relation to the relaxed atmosphere, which is promoted at the home in relation to visitations. The Hazelford Care Home DS0000008689.V270162.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16. Procedures are in place for residents to complain and service users spoken with felt that any concerns would be listened to and acted upon accordingly. EVIDENCE: The complaints procedure is now included in the Statement of Purpose as a response to a requirement from a previous inspection. The complaints procedure is also on display within the foyer of the home to allow service users and their relatives easy perusal. Service users spoken with said that they would not hesitate to raise any concerns or complaints with the care staff or the manager at the home and that they were confident in the manager’s ability to address any elements of a complaint in a sensitive and professional manner. At the time of the inspection the manager of the home was not investigating any complaints and the Commission for Social Care Inspection had not received any complaints whatsoever. One service users spoken with stated that she had been in the home for many months and had never witnessed anything which gave her concern or would initiate the complaints procedure. The Hazelford Care Home DS0000008689.V270162.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19. Hazelford Residential Home offers a very homely, comfortable and safe environment for service users, the home is maintained to a high standard and is clean and hygienic throughout. EVIDENCE: A partial tour of the premises was completed as part of this inspection. The accommodation was well decorated, very comfortably furnished and maintained to a good standard. A handyman deals with any shortfalls within the home environment effectively The gardens are attractive and accessible to service users in wheelchairs. A large very pleasant patio area, which faces the River Trent is available, the area is equipped with tables and chairs thus providing a very agreeable area for the service users and their relatives and friends to utilise on hot summer days. The Hazelford Care Home DS0000008689.V270162.R01.S.doc Version 5.1 Page 17 A handyman is employed at the home for 25 hours per week. The temperatures of water outlets are monitored on a monthly basis and emergency lighting and fire alarm checks are performed on a weekly basis. Shower temperatures are monitored and the handyman at the unit also chlorinates all showerheads within the unit to control Legionella contamination. All mobility equipment within the unit is covered by service contracts to ensure service user safety. It was also evidence that the handyman initiates fire drills on a weekly basis. The handyman and the manager of the unit also perform internal and external examination of the home to ensure the environment is safe and fit for purpose. The Hazelford Care Home DS0000008689.V270162.R01.S.doc Version 5.1 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27. 29. 30 Care staff employed on the day of the inspection was sufficient to meet the identified needs of the service users. The recruitment policy utilised at the home had not been fully adhered to thus resulting a potential risk to service users. Documentation appertaining to the training opportunities provided to care staff at the home does not clearly evidence that staff at the home are appropriately trained. EVIDENCE: On the day of the inspection 29 service users were accommodated at the home. Staffing levels were appropriate to meet the needs of the service users. Four carers were on duty throughout the morning period and afternoon period, and three carers covered the night period. The home does not employ any qualified nurses, as the home does not provide nursing services. The manager hours are not included within the care staff rotas so as to provide the opportunity to effectively manage the home although the deputy managers hours are included within the care staff rota. Staff files evidenced that recruitment policies and procedures had not been fully adhered to in the past as not all the required checks such as Criminal The Hazelford Care Home DS0000008689.V270162.R01.S.doc Version 5.1 Page 19 Records Bureau checks and Protection of Vulnerable Adult “first” checks had been obtained prior to employment. The Commission for Social Care Inspection will require an action plan that clearly identifies how the manager at the home will address the identified shortfall by 31/03/06. Over 50 of the care staff have completed level 2 National Vocational Qalifications (NVQ) and it was also stated by the manager of the home that staff have received “in house” training opportunities appertaining to the statutory training requirements for care staff. A member of care staff was interviewed at the time of the inspection and it was apparent that she had appropriate knowledge in relation to the protection of the vulnerable adult and infection control principles, knowledge that was gleaned from the “in house” training. The staff-training matrix utilised at the home did not adequately demonstrate that the staff have been given the statutory training required from an accredited trainer to enable them to maintain their own and the service users’ health and safety. (That is Basic Food Hygiene, Basic First Aid, Moving and Handling, Prevention of Cross Infection and Health and Safety. The Commission for Social Care Inspection will require an action plan which clearly identifies the training provision afforded to cares at the home together with any planned training events within the year 2006 by 31/03/06,thus demonstrating that staff maintain their own and the service users’ health and safety through appropriate training opportunities. The Hazelford Care Home DS0000008689.V270162.R01.S.doc Version 5.1 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 35. A clear financial audit trail could be established for all service users and elements appertaining to Regulation 20 are adhered to at Hazelford Residential Home. EVIDENCE: At the time of the inspection it was evidenced that the service users monies are effectively managed. The manager of the home could clearly demonstrate a financial audit trail for service users accommodated at the home, extra interventions, not included in the “care package” at the home, such as podiatry services and hairdressing etc had receipts evident thus protecting the service users from financial abuse. . The Hazelford Care Home DS0000008689.V270162.R01.S.doc Version 5.1 Page 21 All financial documentation appertaining to service users are stored in a secure area which the manager and her deputy have exclusive access to thus ensuring that service users confidential information is protected as far as practicably possible. The Hazelford Care Home DS0000008689.V270162.R01.S.doc Version 5.1 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. 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 3 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 4 X X X X X X X STAFFING Standard No Score 27 3 28 X 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X x The Hazelford Care Home DS0000008689.V270162.R01.S.doc Version 5.1 Page 23 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 7 Regulation 15 (1) Requirement The registered person shall ensure after consultation with the service user, or a representative of his, prepare a written plan as to how the service users needs in respect of his health and welfare are to be met. The registered person shall ensure that the assessment of the service user’s needs is kept under review and revised at any time when it is necessary to do so having regard to any change of circumstances. The provider shall ensure that any activities in which service users participate in are so far as reasonably practicable free from avoidable risk. The provider shall ensure that new staff are confirmed in post only following completion of a satisfactory police check, and satisfactory check of the Protection of Children and Vulnerable Adults and have supplies two satisfactory references. The registered provider shall DS0000008689.V270162.R01.S.doc Timescale for action 31/03/06 2 8 17 31/03/06 3 9 13 (4) (b) 31/03/06 4 29 19 31/03/06 5 30 18 (1) (c) 31/03/06 Page 24 The Hazelford Care Home Version 5.1 ensure that person employed by the registered provider to work at the care home receive appropriate training to the work they are to perform. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Hazelford Care Home DS0000008689.V270162.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Hazelford Care Home DS0000008689.V270162.R01.S.doc Version 5.1 Page 26 - 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!