Care Home: Care Homes UK Ltd T A Hazelroyd Nursing Home

Similar services:

• Abbey The
• Snydale Care Home
• Larchfield Manor
• Hawkhills
• Beeches The - North Yorkshire County Council
• Carentan House
• Ravensworth Lodge

What the care home does well Hazelroyd Nursing Home DS0000065574.V378088.R02.S.doc Version 5.2 Anyone thinking of moving into Hazelroyd can go and look around to see for themselves if they think the home is suitable for them. If they decide to move in one of the nurses will carry out an assessment to make sure that they can meet that persons needs and arrange a day for admission. Each person has an individual care plan that sets out what care and support they require from staff. The medication system is generally well managed and people get their medication at the right times. This makes sure people consistently receive the care they need. People look well cared for. All the people who live in the home spoke well of staff and said they felt that they were kind and caring. Staff arrange some activities to keep people stimulated. People can follow their own routines and relatives and friends are welcome to visit at any time. Relatives told us that they are made to feel welcome when they visit. There is a complaints procedure in place and any concerns or complaints that have been made have been taken seriously and dealt with. Meals at the home are good and offer people choice and variety. The home is clean and tidy and odour free. Bedrooms have been personalised and people have a lot of their own possessions with them. There are enough staff on duty to meet people’s needs and more than half of the care staff are qualified and have been assessed as competent in their role. What has improved since the last inspection? The documentation in the care plans has improved and it is easy to find out what people’s needs are and what action staff need to take to meet those needs. This helps staff to make sure people consistently receive the care they need. There have been some good improvements to the environment. Two of the lounges have been redecorated and have new carpets and curtains. New floor covering has been put down outside of the kitchen and one of the bedrooms has been treated for damp and the decorative standard has been made good following the treatment.Hazelroyd Nursing HomeDS0000065574.V378088.R02.S.docVersion 5.2One of the lounges has been made into an activities room and has a wide range of reminiscence material and games for people to use. Staffing levels are appropriate for the number of people living in the home at the moment. This means there are enough staff to meet people’s needs. The home have completed their own quality assurance survey to get the views of people living in the home. They have taken action to improve on the areas that people thought could be better. This means that they are listening to people views and taking action to improve the service. Monthly visits and reports are being written about the home. This means that checks are in place to make sure that the home is being managed properly. The fire alarms are being tested weekly to make sure that the system is working properly and would activate if a fire broke out. What the care home could do better: Some of the paperwork that is given to people needs to be updated so they have the details of the Care Quality Commission and how to contact us if they need to. Staff need to make sure that the daily records reflect the care and support they have given people and whether or not the outcomes of that persons care plan have been met. This will make sure staff can check that people’s needs are being met consistently. Staff need to make sure that they always maintain people’s dignity. Staff need to make sure that they sign the medication administration records to show that they have applied any topical creams or lotions that have been prescribed. This will make sure that people are receiving them as directed. The recruitment procedure for staff need to be tightened up to make sure that staff are examining all of the information they have and making additional checks as necessary to make sure people are suitable and safe to work with older people. An audit of money that is held on behalf of people living in the home must take place. This will make sure that records are accurate maintained. The long term management arrangements for the home need to be confirmed and a manager needs to register with us so that there is someone legally responsible for the management of the home.Hazelroyd Nursing HomeDS0000065574.V378088.R02.S.docVersion 5.2 Key inspection report CARE HOMES FOR OLDER PEOPLE Hazelroyd Nursing Home 31 - 33 Savile Road Halifax HX1 2EN Lead Inspector Paula McCloy Key Unannounced Inspection 16th October 2009 10:00 DS0000065574.V378088.R02.S.do c Version 5.3 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. Hazelroyd Nursing Home DS0000065574.V378088.R02.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 Hazelroyd Nursing Home DS0000065574.V378088.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hazelroyd Nursing Home Address 31 - 33 Savile Road Halifax HX1 2EN 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) 01422 362325 01422 300575 hazelroyd@hotmail.co.uk Care Homes UK Ltd Manager post vacant Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Hazelroyd Nursing Home DS0000065574.V378088.R02.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 only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP, maximum number of places 40 The maximum number of service users who can be accommodated is: 40 21st April 2009 2. Date of last inspection Brief Description of the Service: Hazelroyd is a large stone built property that has been adapted and extended for its current use. It is situated on Savile Park Road and is approximately 10 minutes’ walk from Halifax town centre and its amenities. There is car parking to the front and rear of the building. There is a patio area to the rear of the house where people can sit out in fine weather. Hazelroyd is a care home with nursing. It has the provision to accommodate a total of forty older people. The accommodation is arranged over four floors. Hazelroyd has three lounges, a small dining room and conservatory. There are twelve single bedrooms and fourteen double bedrooms. One of the double bedrooms has an en suite toilet. There are seven bathrooms, four of which have assisted bathing facilities and there are five separate toilets. There is a passenger lift that serves all four floors. On the day of our visit the charges at Hazelroyd were £486 per week. Additional charges are made for hairdressing, chiropody and newspapers. Hazelroyd Nursing Home DS0000065574.V378088.R02.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. We inspected Hazelroyd in April 2009 and the service was assessed as being poor. We asked the service to send us an improvement plan to tell us what they were going to do to make the service better. We received this and went back in August 2009 and carried out a random inspection to see what improvements had been made. We found that staff had worked hard to make improvements. This inspection was carried out to assess the quality of care provided to people living at the home. The inspection process included looking at the information we have received about the home since the last key inspection as well as a visit to the home by two regulation inspectors, which lasted approximately 6 hours. During the visit we spoke to 6 people living in the home, 4 members of staff, the manager and 3 relatives. We also observed staff delivering care, looked at various records and looked around the home. Surveys were sent to 10 people living in the home, 10 staff and 5 health care professionals; these cards provide an opportunity for people to share their views of the service with us. Information received in this way is shared with the home without identifying who has provided it. We received five surveys from people living in the home. Their comments have been used in this report. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations, but only when it is considered that people who use the service are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. What the service does well: Hazelroyd Nursing Home DS0000065574.V378088.R02.S.doc Version 5.2 Page 6 Anyone thinking of moving into Hazelroyd can go and look around to see for themselves if they think the home is suitable for them. If they decide to move in one of the nurses will carry out an assessment to make sure that they can meet that persons needs and arrange a day for admission. Each person has an individual care plan that sets out what care and support they require from staff. The medication system is generally well managed and people get their medication at the right times. This makes sure people consistently receive the care they need. People look well cared for. All the people who live in the home spoke well of staff and said they felt that they were kind and caring. Staff arrange some activities to keep people stimulated. People can follow their own routines and relatives and friends are welcome to visit at any time. Relatives told us that they are made to feel welcome when they visit. There is a complaints procedure in place and any concerns or complaints that have been made have been taken seriously and dealt with. Meals at the home are good and offer people choice and variety. The home is clean and tidy and odour free. Bedrooms have been personalised and people have a lot of their own possessions with them. There are enough staff on duty to meet people’s needs and more than half of the care staff are qualified and have been assessed as competent in their role. What has improved since the last inspection? The documentation in the care plans has improved and it is easy to find out what people’s needs are and what action staff need to take to meet those needs. This helps staff to make sure people consistently receive the care they need. There have been some good improvements to the environment. Two of the lounges have been redecorated and have new carpets and curtains. New floor covering has been put down outside of the kitchen and one of the bedrooms has been treated for damp and the decorative standard has been made good following the treatment. Hazelroyd Nursing Home DS0000065574.V378088.R02.S.doc Version 5.2 Page 7 One of the lounges has been made into an activities room and has a wide range of reminiscence material and games for people to use. Staffing levels are appropriate for the number of people living in the home at the moment. This means there are enough staff to meet people’s needs. The home have completed their own quality assurance survey to get the views of people living in the home. They have taken action to improve on the areas that people thought could be better. This means that they are listening to people views and taking action to improve the service. Monthly visits and reports are being written about the home. This means that checks are in place to make sure that the home is being managed properly. The fire alarms are being tested weekly to make sure that the system is working properly and would activate if a fire broke out. What they could do better: Some of the paperwork that is given to people needs to be updated so they have the details of the Care Quality Commission and how to contact us if they need to. Staff need to make sure that the daily records reflect the care and support they have given people and whether or not the outcomes of that persons care plan have been met. This will make sure staff can check that people’s needs are being met consistently. Staff need to make sure that they always maintain people’s dignity. Staff need to make sure that they sign the medication administration records to show that they have applied any topical creams or lotions that have been prescribed. This will make sure that people are receiving them as directed. The recruitment procedure for staff need to be tightened up to make sure that staff are examining all of the information they have and making additional checks as necessary to make sure people are suitable and safe to work with older people. An audit of money that is held on behalf of people living in the home must take place. This will make sure that records are accurate maintained. The long term management arrangements for the home need to be confirmed and a manager needs to register with us so that there is someone legally responsible for the management of the home. Hazelroyd Nursing Home DS0000065574.V378088.R02.S.doc Version 5.2 Page 8 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. Hazelroyd Nursing Home DS0000065574.V378088.R02.S.doc Version 5.3 Page 9 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 Hazelroyd Nursing Home DS0000065574.V378088.R02.S.doc Version 5.3 Page 10 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): 1, 3 & 5 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. People can get written information and go and look around the home to see for themselves if they think it is suitable place for them to live. EVIDENCE: There is a Statement of Purpose and Service User Guide. This means that people can get written information about the home and the service it offers so they can see if it is suitable for them. We did notice that some of the documents still refer to the Commission for Social Care Inspection these need to be updated with details of the Care Quality Commission. Hazelroyd Nursing Home DS0000065574.V378088.R02.S.doc Version 5.3 Page 11 The acting manager told us if someone is thinking of moving into Hazelroyd a nurse from the home would go and see them and make an assessment as to whether or not the home could meet their needs. This means that no one should move into the home unless staff are sure that they can meet that persons’ needs. There have been no recent admissions to the home and no new assessments for us to look at to make a judgement about their quality. The assessment document that staff use is comprehensive and covers all of the areas we would expect to find. People can visit the home themselves to look around and stay for a meal if they wish so that they can see if they think the home is suitable. The home does not offer intermediate care. Hazelroyd Nursing Home DS0000065574.V378088.R02.S.doc Version 5.3 Page 12 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. People’s personal and health care needs are generally being met. However, people’s dignity is not always maintained. EVIDENCE: We looked at three care plans because we wanted to see what individual needs had been identified and what action staff have to take to meet these needs. We found that the care plans were detailed and contained good information. All of the necessary risk assessments have been completed and staff are writing down the action they need to take to reduce or eliminate that risk. For example one person had been identified as being at risk of developing pressure sores. There was a clear plan regarding the specialist equipment that was in place and instructions for staff to monitor closely their skin condition. Hazelroyd Nursing Home DS0000065574.V378088.R02.S.doc Version 5.3 Page 13 Peoples health care needs are being identified and met. Staff are vigilant and GPs and other health care professionals are being involved as necessary. In the surveys five people living in the home confirmed that they get the medical support that they need. On the day of our visit the nurse on duty insisted that one person needed a visit from her GP and a visit duly took place. Details of any visits by health care professionals are documented in the individual care plan and give details of the advice that has been given. The acting manager told us that the home will be getting a specialist piece of equipment so that people’s ongoing moving and handling needs will be met. The business manger told us that she was in the process of finding a suitable piece of equipment. In the surveys people living in the home told us that they get the care and support they need and that staff listen to them. However, the daily records do not always reflect the care and support that staff are giving. For example how people’s personal hygiene and continence needs have been met. The acting manager is aware of this and is meeting with the nurses to look at care planning and recording. It is important that staff write down the care and support they give so they can demonstrate people’s care is being delivered as detailed in the care plan. This will make sure that people’s needs are met in a consistent way. People looked well cared for and we saw that men had been shaved, peoples hair brushed or combed, spectacles were clean and peoples personal hygiene was well maintained. However, staff need to be more vigilant as one person had not had their mouth wiped after breakfast and another had been left in a chair with no knee blanket, which was undignified for them. The people we spoke to told us that generally they like the staff and that they respond to their requests. The medication system is well managed and all staff who give out medication have received training. We watched part of a medication round. The nurse spent time with each individual, offering encouragement when needed. People are receiving their medication at the prescribed times and generally records are well maintained. We did note that none of the lotions or creams that have been prescribed are being signed for. It is important that the staff who apply these sign the medication records to show that people have received the treatment as prescribed by their doctor. We spoke to the acting manager about this and she agreed to make sure this happens in future. Hazelroyd Nursing Home DS0000065574.V378088.R02.S.doc Version 5.3 Page 14 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. There are activities available to keep people stimulated. The meals at the home are good offering choice and variety. EVIDENCE: The care plans we looked at all contained a life history and details of people’s personal preferences and likes and dislikes. This is important because it makes sure staff know about people’s past lives and experiences. It also makes sure they know what times people like to get up, go to bed, if they like to stay in their bedroom and what they like and don’t like to eat and drink. One of the lounges had been made into an activities room, there are a range of games and memorabilia available for people to use. Staff are also in the process of making a memory box with each person living there, which will contain items personal to them that can be use as conversation topics. We saw staff using photographs with one person, which generated a lot of good interaction. Hazelroyd Nursing Home DS0000065574.V378088.R02.S.doc Version 5.3 Page 15 Staff at the home are arranging the activities at the current time. The acting manager is hoping to recruit an activities organiser so that dedicated staff will be responsible for delivering the activities programme. Relatives we spoke to told us that they are made to feel welcome and that the staff are friendly and available. People told us that meals at the home are good and that there is a choice available for every meal. At lunchtime people ate in the dining room, activities room, lounges or their bedroom. Tables were nicely set with a full range of condiments and serviettes. Staff made sure that the people who needed assistance got the help that they required. Hazelroyd Nursing Home DS0000065574.V378088.R02.S.doc Version 5.3 Page 16 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. Complaints and adult protection issues are being dealt with properly. This means that staff are listening to people and keeping them safe. EVIDENCE: The homes complaints procedure is not on display but it is in the Service User Guide. We noted that the complaints procedure needs updating with the details of the Care Quality Commission as it is referring people to our old organisation. People told us that they know who to talk to if they are unhappy or if they want to make a complaint. The acting manager told us that a copy of the complaints procedure is being sent out to all of the relatives, to make sure that they know what to do if they are not happy about the service. The acting manager told us that she has received two complaints recently that she is dealing with. She is aware that she needs to record these in the complaints log together with the action she has taken and outcome. This will make sure complaints are dealt with properly and can be analysed to see if there are any recurrent themes that need to be addressed. The staff we spoke to were able to tell us what they would do if they felt there were any practices in the home that werent in the best interest of the people Hazelroyd Nursing Home DS0000065574.V378088.R02.S.doc Version 5.3 Page 17 living there. They also said that they had completed adult protection training. We could see from the training records that staff have done this training. This means that staff are fully aware of all of the different types of abuse and about the reporting procedures. Hazelroyd Nursing Home DS0000065574.V378088.R02.S.doc Version 5.3 Page 18 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, 20, 24 & 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. The home is clean, comfortable and tidy. Improvements to the environment are ongoing. EVIDENCE: The home is close to Halifax town centre and all of its amenities. There is a patio area that people can use safely in fine weather and car parking to the front and rear of the building. There is an ongoing redecoration and refurbishment programme in place. Since our visit in April 2009 two lounges have been redecorated, a problem with damp in one bedroom has been resolved and the floor covering outside of the kitchen has been replaced. At the time of our visit work was starting on Hazelroyd Nursing Home DS0000065574.V378088.R02.S.doc Version 5.3 Page 19 the redecoration off the main entrance and staircase. It is important that this programme continues to make sure that the accommodation is maintained to a good standard. Some of the people sitting in the lounge next to the nurses office told us they would like a clock on the wall so they can easily find out what the time is. The old smoking lounge has now been turned into an activities room. The acting manager told us that this area was also going to be redecorated in the near future. The kitchen was awarded 5* for hygiene when it was last inspected by environmental health. This means that the hygiene standards are excellent. The acting manager has given the house keeping staff responsibility for designated areas. When we looked around the home we found it clean and tidy. People’s bedrooms looked well cared for and rooms were very individual and had been personalised to people’s taste. People living in the home told us that the standard of cleanliness is good and the home is kept fresh and clean. The laundry is well equipped in the last survey that was done in the home people had some issues about the laundry, since then the laundry service has been improved. Hazelroyd Nursing Home DS0000065574.V378088.R02.S.doc Version 5.3 Page 20 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. There are enough staff on duty to meet people’s needs and care staff have been assed as competent to deliver care and support. EVIDENCE: At the time of this visit, there were 21 people living at the home and one person was in hospital. The duty rotas showed that, during the day, there is one nurse on duty with 5 care staff in the mornings and 3/4 care staff in the evenings. At night, there is one nurse and two care assistants on duty. There has been some reduction in the staffing levels in the evening and at night since our last visit because there are less people living in the home at the current time. The acting manager is aware that she needs to keep the staffing levels under review as people are admitted to the home or as people’s needs change. The care staff are well supported by cooks, house keepers, kitchen assistants and a handy person. At the time of our visit the acting manager was interviewing for an administrator. This post has been created to give the acting manager support with some of the office tasks and administration. Hazelroyd Nursing Home DS0000065574.V378088.R02.S.doc Version 5.3 Page 21 On previous visits we have been concerned about the lack of supervision in the lounges, when care staff are busy elsewhere in the building. The acting manager has addressed this and from 19 October 2009 a specific member of staff will be responsible for supervising the lounges, making sure people get their drinks and that their personal appearance is how they would wish. We talked to staff about the staffing levels. They felt that at the current time the staffing levels are adequate to meet people’s needs. We looked at some of the records relating to three recently recruited staff to see if staff are properly checked before they start work at the home. We found all of the necessary checks in place for people but the files need auditing to make sure they all follow a standard format. This will make information easy to find and check that the files are up to date. Photographs of the staff have been taken and now need to be added to their files. At our visit in August 2009 we made some good practice recommendations about recruitment of staff. We asked them to make sure on the application forms people recorded more information about their past employment, that two people interviewed prospective staff and that a written record of any interviews were maintained. We also asked for the reference request letter to be improved to ask for some more information. Unfortunately the service did not receive the first copy of the report that was sent to them, which has meant that they haven’t had the opportunity to implement those recommendations. We have therefore included them in this report. There are nineteen care staff working in the home, over half of the care staff have completed their NVQ (National Vocational Training) level 2 or 3 in care. This means that staff are trained and have been assessed as competent to do their job. Hazelroyd Nursing Home DS0000065574.V378088.R02.S.doc Version 5.3 Page 22 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 & 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 overall management of the home has improved and people living there are being asked for their opinion of the service. EVIDENCE: There has been no registered manager at the home since before the new owners took over in February 2006. After the inspection in November 2007 a manager was recruited but she has left the home. Following the inspection in May 2008 a manager was recruited but she also left. Another manager started in November 2008 and applied for registration with us but did not complete the process and she left in September 2009. The current acting manager is a Hazelroyd Nursing Home DS0000065574.V378088.R02.S.doc Version 5.3 Page 23 nurse who has worked at the home for about 12 months and has taken responsibility for training and the clinical nurse lead. Since the inspection in April 2009 the acting manager and staff have worked hard to bring about improvements. These improvements now need to be consolidated and developed. This will make sure the service keeps moving forward. The home completed an Annual Quality Assurance Assessment (AQAA) when we asked for it prior to our inspection. We also asked them to send us an improvement plan after the inspections in April and August. They did this and from their response we could see what changes they had made to make the service better and to meet the requirements we had made following those visits. We found that the home has carried out its own quality assurance survey and has put together an action plan to address most of the points raised. This means that people are being consulted about the service they receive and the manager is acting upon what they say. We found that reports from the Responsible Individual or their designated representative for April, June, July and September 2009 were available at the home. A new form for these visits has been developed, which should improve the quality of the reports. These detailed any action that was needed from the provider and manager to make sure the home is being managed properly. The acting manager does hold money for safekeeping. We looked at the records and found them unclear. Records were not up to date and the balance of money held for one person was more than the recorded balance on the written record. All of the money held for people need to be audited and the records brought up to date. This will make sure that people are protected from any financial abuse. There is no one currently living in the home who is subject to a deprivation of liberty authorisation. It is important that staff receive training about the Mental Capacity Act and Deprivation of Liberty Safeguards so that they understand the implications in their day to day work with people. In the improvement plan the responsible person has told us that all of the kitchen staff have completed food hygiene training and care staff have received moving and handling training. In relation to first aid training the responsible person has told us that he is following our guidance and will complete a risk assessment to ensure that the home has the correct level of cover at all times. The fire alarms were tested during our visit. The acting manager told us that they are checked every week to make sure they are working properly. In the Hazelroyd Nursing Home DS0000065574.V378088.R02.S.doc Version 5.3 Page 24 improvement plan we were told that the fire alarm system was serviced in July and all of the work that was needed on the passenger lift has been completed. Hazelroyd Nursing Home DS0000065574.V378088.R02.S.doc Version 5.3 Page 25 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 2 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 X X X 3 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 2 X 3 X 2 X X 2 Hazelroyd Nursing Home DS0000065574.V378088.R02.S.doc Version 5.3 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement The daily records kept for people must reflect the content of the individual’s care plan and whether or not outcomes of the care plan have been met for the individual. This will make sure people are getting the care and support they need. A system must be put in place to make sure that staff sign the medication administration records to show that topical creams and lotions have been applied. This will make sure people receive treatments as prescribed. Staff must make sure that people’s privacy and dignity is maintained at all times. This will make sure that people are treated with respect. An audit of all money held on behalf of people living in the home must take place and you DS0000065574.V378088.R02.S.doc Timescale for action 31/12/09 2 OP9 13 (2) 07/12/09 3 OP10 12 07/12/09 4 OP35 17 07/12/09 Hazelroyd Nursing Home Version 5.3 Page 27 must provide the Commission with written evidence this has been carried out and what has been found. This will make sure that all of the records are accurate and people are not at risk of any financial abuse. 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 OP1 Good Practice Recommendations The Statement of Purpose and Service User Guide should be updated to give the contact details for the Care Quality Commission (CQC). This will make sure that people know who is responsible for regulating the service. The additional moving and handling equipment that the home needs should be made available. This will make sure people’s ongoing moving and handling needs are met. The complaints procedure should be updated and put on display. This will make sure people can refer to the procedure if they need to. The redecoration and refurbishment programme should continue. This will make sure the home is kept in good order. On application forms prospective staff should record details of the month when recording their past employment histories. This will allow managers to fully explore any gaps in employment. There should be two people interviewing prospective staff. This will make sure interviews are conducted in line with equal opportunities guidance. A record of people’s interviews should be made. This will make sure details are available if needed. Reference request letters should be improved and ask the referee in what capacity they knew the applicant and where possible to provide a business stamp. This will help to validate references and make sure that the manager knows exactly who references are from. DS0000065574.V378088.R02.S.doc Version 5.3 Page 28 2 3 4 5 OP8 OP16 OP19 OP29 6 7 8 OP29 OP29 OP29 Hazelroyd Nursing Home 9 OP29 10 OP30 11 OP31 12 OP38 The introduction of a recruitment checklist should be considered. This will help to quickly establish exactly where the recruitment process is up to and what documents are still outstanding. All staff should complete Mental Capacity Act and Deprivation of Liberty training. This will make sure that they fully understand the implications in their day to day work. The long term management arrangements for the home should be confirmed and an application make to us to register a manager. This will make sure there is someone legally responsible for the management of the home. A copy of the homes risk assessment about how first aid training and cover will be provided should be sent to us. This will make sure the home is following our guidance. Hazelroyd Nursing Home DS0000065574.V378088.R02.S.doc Version 5.3 Page 29 Care Quality Commission Care Quality Commission Citygate Gallowgate Newcastle Upon Tyne NE1 4PA 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. Hazelroyd Nursing Home DS0000065574.V378088.R02.S.doc Version 5.3 Page 30 - 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!